Reed S, Arnal D, Frank O, Gomez-Arnau J I, Hansen J, Lester O, Mikkelsen K L, Rhaiem T, Rosenberg P H, St Pierre M, Schleppers A, Staender S, Smith A F
Department of Anaesthesia, Royal Lancaster Infirmary, Lancaster, UK.
Br J Anaesth. 2014 Mar;112(3):546-55. doi: 10.1093/bja/aet406. Epub 2013 Dec 5.
Critical incident reporting is a key tool in the promotion of patient safety in anaesthesia.
We surveyed representatives of national incident reporting systems in six European countries, inviting information on scope and organization, and intelligence on factors determining success and failure.
Some systems are government-run and nationally conceived; others started out as small, specialty-focused initiatives, which have since acquired a national reach. However, both national co-ordination and specialty enthusiasts seem to be necessary for an optimally functioning system. The role of reporting culture, definitional issues, and dissemination is discussed.
We make recommendations for others intending to start new systems and speculate on the prospects for sharing patient safety lessons relevant to anaesthesia at European level.
危急事件报告是促进麻醉领域患者安全的关键工具。
我们对六个欧洲国家的国家事件报告系统代表进行了调查，收集有关范围和组织的信息，以及关于决定成败因素的情报。
一些系统由政府运营且全国统一规划；其他系统则始于小型的、专注于特定专业的倡议，后来发展到全国范围。然而，对于一个运作良好的系统而言，国家层面的协调和专业领域的热心人士似乎都是必不可少的。文中讨论了报告文化、定义问题及传播的作用。
我们为有意启动新系统的其他人提出建议，并推测在欧洲层面分享与麻醉相关的患者安全经验教训的前景。
