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从西班牙国家卫生系统患者安全事件报告与学习系统(SiNASP)的开发中汲取的经验教训。

Lessons learnt from the development of the Patient Safety Incidents Reporting an Learning System for the Spanish National Health System: SiNASP.

作者信息

Vallejo-Gutiérrez Paula, Bañeres-Amella Joaquim, Sierra Eduardo, Casal Jesús, Agra Yolanda

机构信息

Instituto Universitario Avedis Donabedian (FAD), Spain; Universitat Autònoma de Barcelona, Barcelona, Spain; Red de investigación en servicios de salud en enfermedades crónicas (REDISSEC), Spain.

Instituto Universitario Avedis Donabedian (FAD), Spain; Universitat Autònoma de Barcelona, Barcelona, Spain; Red de investigación en servicios de salud en enfermedades crónicas (REDISSEC), Spain.

出版信息

Rev Calid Asist. 2014 Mar-Apr;29(2):69-77. doi: 10.1016/j.cali.2013.09.007. Epub 2013 Nov 9.

Abstract

OBJECTIVE

To describe the development process and characteristics of a patient safety incidents reporting system to be implemented in the Spanish National Health System, based on the context and the needs of the different stakeholders.

DESIGN

Literature review and analysis of most relevant reporting systems, identification of more than 100 stakeholder's (patients, professionals, regional governments representatives) expectations and requirements, analysis of the legal context, consensus of taxonomy, development of the software and pilot test.

RESULTS

Patient Safety Events Reporting and Learning system (Sistema de Notificación y Aprendizajepara la Seguridad del Paciente, SiNASP) is a generic reporting system for all types of incidents related to patient safety, voluntary, confidential, non punitive, anonymous or nominative with anonimization, system oriented, with local analysis of cases and based on the WHO International Classification for Patient Safety. The electronic program has an on-line form for reporting, a software to manage the incidents and improvement plans, and a scoreboard with process indicators to monitor the system.

CONCLUSIONS

The reporting system has been designed to respond to the needs and expectations identified by the stakeholders, taking into account the lessons learned from the previous notification systems, the characteristics of the National Health System and the existing legal context. The development process presented and the characteristics of the system provide a comprehensive framework that can be used for future deployments of similar patient safety systems.

摘要

目的

基于不同利益相关者的背景和需求,描述西班牙国家卫生系统中即将实施的患者安全事件报告系统的开发过程及特点。

设计

对最相关的报告系统进行文献综述与分析,识别100多名利益相关者(患者、专业人员、地区政府代表)的期望和要求,分析法律背景,确定分类法共识,开发软件并进行试点测试。

结果

患者安全事件报告与学习系统(Sistema de Notificación y Aprendizaje para la Seguridad del Paciente,SiNASP)是一个针对所有与患者安全相关的各类事件的通用报告系统,具有自愿性、保密性、非惩罚性、匿名或可匿名化的实名报告功能,以系统为导向,对病例进行本地分析,并基于世界卫生组织国际患者安全分类。该电子程序有一个在线报告表单、一个用于管理事件和改进计划的软件,以及一个带有过程指标的记分板来监测系统。

结论

该报告系统旨在满足利益相关者确定的需求和期望,同时考虑到从以前的报告系统中吸取的经验教训、国家卫生系统的特点以及现有的法律背景。所呈现的开发过程和系统特点提供了一个全面的框架,可用于未来类似患者安全系统的部署。

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