Chamberlain James M, Shaw Kathy N, Lillis Kathleen A, Mahajan Prashant V, Ruddy Richard M, Lichenstein Richard, Olsen Cody S, Dean J Michael
Division of Emergency Medicine, Children's National Medical Center, Washington, DC 20010, USA.
Pediatr Emerg Care. 2013 Feb;29(2):125-30. doi: 10.1097/PEC.0b013e31828043a5.
Hospital incident reporting is widely used but has had limited effectiveness for improving patient safety nationally. We describe the process of establishing a multi-institutional safety event reporting system.
A descriptive study in The Pediatric Emergency Care Applied Research Network of 22 hospital emergency departments was performed. An extensive legal analysis addressed investigators' concerns about sharing confidential incident reports (IRs): (1) the ability to identify sites and (2) potential loss of peer review statute protection. Of the 22 Pediatric Emergency Care Applied Research Network sites, 19 received institutional approval to submit deidentified IRs to the data center. Incident reports were randomly assigned to independent review; discordance was resolved by consensus. Incident reports were categorized by type, subtype, severity, staff involved, and contributing factors.
A total of 3,106 IRs were submitted by 18 sites in the first year. Reporting rates ranged more than 50-fold from 0.12 to 6.13 per 1000 patients. Data were sufficient to determine type of error (90% of IRs), severity (79%), staff involved (82%), and contributing factors (82%). However, contributing factors were clearly identified in only 44% of IRs and required extrapolation by investigators in 38%. The most common incidents were related to laboratory specimens (25.5%), medication administration (19.3%), and process variance, such as delays in care (14.4%).
Incident reporting provides qualitative data concerning safety events. Perceived legal barriers to sharing confidential data can be addressed. Large variability in reporting rates and low rates of providing contributing factors suggest a need for standardization and improvement of safety event reporting.
医院事件报告被广泛使用，但在全国范围内改善患者安全方面效果有限。我们描述了建立多机构安全事件报告系统的过程。
在儿科急诊护理应用研究网络的22个医院急诊科进行了一项描述性研究。进行了广泛的法律分析，以解决研究人员对共享机密事件报告（IRs）的担忧：（1）识别地点的能力；（2）同行评审法规保护的潜在丧失。在22个儿科急诊护理应用研究网络站点中，19个获得了机构批准，可将去识别化的IRs提交至数据中心。事件报告被随机分配进行独立审查；不一致之处通过协商解决。事件报告按类型、子类型、严重程度、涉及人员和促成因素进行分类。
第一年，18个站点共提交了3106份IRs。报告率从每1000名患者0.12至6.13不等，相差超过50倍。数据足以确定错误类型（90%的IRs）、严重程度（79%）、涉及人员（82%）和促成因素（82%）。然而，仅44%的IRs中明确识别出了促成因素，38%需要研究人员进行推断。最常见的事件与实验室标本（25.5%）、用药管理（19.3%）以及流程差异（如护理延迟，14.4%）有关。
事件报告提供了有关安全事件的定性数据。可以解决共享机密数据时感知到的法律障碍。报告率的巨大差异和促成因素提供率较低表明需要对安全事件报告进行标准化和改进。
