Department of Computer Science and Information Engineering, Healthy Aging Research Center, Chang Gung University, Taiwan.
Int J Med Inform. 2012 Dec;81(12):834-41. doi: 10.1016/j.ijmedinf.2012.08.007. Epub 2012 Sep 19.
The aim of this study is to create a national database to record incidents that endanger patient safety. We try to identify systemic problems in hospitals in order to avoid safety incidents in the future and improve the quality of healthcare.
The Taiwan Patient Safety Reporting System employs a voluntary notification model. We define 13 types of patient safety incidents, and the reports of different types of incidents are recorded using common terminology. Statistical analysis is used to identify the incident type, time of occurrence, location, person who reported the incident, and possible reasons for frequently occurring incidents.
There were 340 hospitals that joined this program from 2005 to 2010. Over 128,271 incident events were reported and analyzed. The three most common incidents were drug-related incidents, falls, and endo tube related incidents. By analyzing the time of occurrence of incidents, we found that drug-related incidents usually occurred between 8 and 10 am. Falls and endo tube incidents usually occurred between 4 and 6 am. The most common location was wards (57.6%), followed by intensive care areas (13.5%), and pharmacies (9.1%). Among hospital staff, nurses reported the highest number of incidents (68.9%), followed by pharmacists (14.5%) and administrative staff (5.5%). The number of incidents reported by doctors was much lower (1.2%). Most staff members who reported incidents had been working for less than five years (58.1%).
The unified reporting system was found to improve the recording and analysis of patient safety incidents. To encourage hospital staff to report incidents, hospitals need to be assisted in establishing an internal report and management system for safety incidents. Hospitals also need a protection mechanism to allow staff members to report incidents without the fear of punishment. By identifying the root causes of safety incidents and sharing the lessons learned across hospitals is the only way such incidents can be stopped from happening again.
本研究旨在建立一个全国性的数据库，以记录危及患者安全的事件。我们试图找出医院中的系统性问题，以避免未来发生安全事件，并提高医疗质量。
台湾患者安全通报系统采用自愿通报模式。我们定义了 13 种类型的患者安全事件，不同类型的事件报告采用通用术语记录。采用统计分析方法识别事件类型、发生时间、发生地点、报告事件的人员以及经常发生事件的可能原因。
2005 年至 2010 年期间，共有 340 家医院加入该计划。报告并分析了超过 128271 起事件。最常见的三种事件是药物相关事件、跌倒和内镜相关事件。通过分析事件发生时间，我们发现药物相关事件通常发生在上午 8 点至 10 点之间。跌倒和内镜事件通常发生在凌晨 4 点至 6 点之间。最常见的地点是病房（57.6%），其次是重症监护区（13.5%）和药房（9.1%）。在医院工作人员中，护士报告的事件最多（68.9%），其次是药剂师（14.5%）和行政人员（5.5%）。报告事件的医生人数要少得多（1.2%）。报告事件的工作人员中，工作年限不足 5 年的占多数（58.1%）。
统一的报告系统被发现改善了患者安全事件的记录和分析。为了鼓励医院工作人员报告事件，需要协助医院建立内部报告和安全事件管理系统。医院还需要一个保护机制，让工作人员在报告事件时不必担心受到惩罚。通过确定安全事件的根本原因并在医院之间分享经验教训，才能防止此类事件再次发生。
