Pham Julius Cuong, Girard Thierry, Pronovost Peter J
Department of Emergency Medicine, Department of Anesthesia and Critical Care Medicine, Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine , Baltimore, MD, USA.
J Public Health Res. 2013 Dec 1;2(3):e27. doi: 10.4081/jphr.2013.e27.
Incident Reporting Systems (IRS) are and will continue to be an important influence on improving patient safety. They can provide valuable insights into how and why patients can be harmed at the organizational level. However, they are not the panacea that many believe them to be. They have several limitations that should be considered. Most of these limitations stem from inherent biases of voluntary reporting systems. These limitations include: i) IRS can't be used to measure safety (error rates); ii) IRS can't be used to compare organizations; iii) IRS can't be used to measure changes over time; iv) IRS generate too many reports; v) IRS often don't generate in-depth analyses or result in strong interventions to reduce risk; vi) IRS are associated with costs. IRS do offer significant value; their value is found in the following: i) IRS can be used to identify local system hazards; ii) IRS can be used to aggregate experiences for uncommon conditions; iii) IRS can be used to share lessons within and across organizations; iv) IRS can be used to increase patient safety culture. Moving forward, several strategies are suggested to maximize their value: i) make reporting easier; ii) make reporting meaningful to the reporter; iii) make the measure of success system changes, rather than events reported; iv) prioritize which events to report and investigate, report and investigate them well; v) convene with diverse stakeholders to enhance the value of IRS. Significance for public healthIncident Reporting Systems (IRS) are and will continue to be an important influence on improving patient safety. However, they are not the panacea that many believe them to be. They have several limitations that should be considered when utilizing them or interpreting their output: i) IRS can't be used to measure safety (error rates); ii) IRS can't be used to compare organizations; iii) IRS can't be used to measure changes over time; iv) IRS generate too many reports; v) IRS often don't generate in-depth analyses or result in strong interventions to reduce risk; vi) IRS are associated with costs. Moving forward, several strategies are suggested to maximize their value: i) make reporting easier; ii) make reporting meaningful to the reporter; iii) make the measure of success system changes, rather than events reported; iv) prioritize which events to report and investigate, do it well; v) convene with diverse stakeholders to enhance their value.
事件报告系统（IRS）过去是、将来也仍将是提高患者安全的重要影响因素。它们可以提供有关患者在组织层面如何以及为何会受到伤害的宝贵见解。然而，它们并非许多人所认为的万灵药。它们存在一些应予以考虑的局限性。这些局限性大多源于自愿报告系统固有的偏差。这些局限性包括：i）事件报告系统无法用于衡量安全性（错误率）；ii）事件报告系统无法用于比较各组织；iii）事件报告系统无法用于衡量随时间的变化；iv）事件报告系统生成的报告过多；v）事件报告系统往往无法进行深入分析，也无法促成强有力的降低风险干预措施；vi）事件报告系统涉及成本。事件报告系统确实具有重大价值；其价值体现在以下方面：i）事件报告系统可用于识别本地系统危害；ii）事件报告系统可用于汇总罕见情况的经验；iii）事件报告系统可用于在组织内部和组织之间分享经验教训；iv）事件报告系统可用于提升患者安全文化。展望未来，建议采取若干策略以最大化其价值：i）使报告更便捷；ii）使报告对报告者有意义；iii）将成功的衡量标准设定为系统变革，而非所报告的事件；iv）确定报告和调查哪些事件的优先级，并做好报告和调查工作；v）与不同的利益相关者共同商讨，以提升事件报告系统的价值。
对公共卫生的意义
事件报告系统（IRS）过去是、将来也仍将是提高患者安全的重要影响因素。然而，它们并非许多人所认为的万灵药。在使用它们或解读其产出时，应考虑到它们存在的一些局限性：i）事件报告系统无法用于衡量安全性（错误率）；ii）事件报告系统无法用于比较各组织；iii）事件报告系统无法用于衡量随时间的变化；iv）事件报告系统生成的报告过多；v）事件报告系统往往无法进行深入分析，也无法促成强有力的降低风险干预措施；vi）事件报告系统涉及成本。展望未来，建议采取若干策略以最大化其价值：i）使报告更便捷；ii）使报告对报告者有意义；iii）将成功的衡量标准设定为系统变革，而非所报告的事件；iv）确定报告和调查哪些事件的优先级，并做好此事；v）与不同的利益相关者共同商讨，以提升其价值。
