Florence Nightingale School of Nursing and Midwifery, King's College London, London, UK.
Int J Qual Health Care. 2013 Apr;25(2):141-50. doi: 10.1093/intqhc/mzs081. Epub 2013 Jan 18.
Recent critiques of incident reporting suggest that its role in managing safety has been over emphasized. The objective of this study was to examine the perceived effectiveness of incident reporting in improving safety in mental health and acute hospital settings by asking staff about their perceptions and experiences.
Qualitative research design using documentary analysis and semi-structured interviews.
Two large teaching hospitals in London; one providing acute and the other mental healthcare.
Sixty-two healthcare practitioners with experience of reporting and analysing incidents.
Incident reporting was perceived as having a positive effect on safety, not only by leading to changes in care processes but also by changing staff attitudes and knowledge. Staff discussed examples of both instrumental and conceptual uses of the knowledge generated by incident reports. There are difficulties in using incident reports to improve safety in healthcare at all stages of the incident reporting process. Differences in the risks encountered and the organizational systems developed in the two hospitals to review reported incidents could be linked to the differences we found in attitudes to incident reporting between the two hospitals.
Incident reporting can be a powerful tool for developing and maintaining an awareness of risks in healthcare practice. Using incident reports to improve care is challenging and the study highlighted the complexities involved and the difficulties faced by staff in learning from incident data.
最近对事件报告的批评表明，其在安全管理中的作用被高估了。本研究的目的是通过询问工作人员对事件报告的看法和经验，检验事件报告在改善心理健康和急性医院环境安全方面的有效性。
使用文献分析和半结构化访谈的定性研究设计。
伦敦的两家大型教学医院；一家提供急性医疗服务，另一家提供精神卫生保健服务。
62 名有报告和分析事件经验的医疗保健从业者。
事件报告被认为对安全有积极影响，不仅通过改变护理流程，还通过改变员工的态度和知识。工作人员讨论了通过事件报告生成的知识的工具性和概念性使用的例子。在事件报告过程的所有阶段，都存在利用事件报告来提高医疗保健安全性的困难。在两家医院中，由于所遇到的风险和开发的组织系统不同，在报告事件的审查方面存在差异，这可能与我们在两家医院之间发现的对事件报告的态度差异有关。
事件报告可以成为发展和维护医疗实践风险意识的有力工具。利用事件报告来改善护理是具有挑战性的，本研究强调了所涉及的复杂性以及员工从事件数据中学习所面临的困难。
