Jonsson Lena, Gabre Pia
Swed Dent J. 2014;38(3):151-60.
Adverse events cause suffering and increased costs in health care. The main way of registering adverse event is through dental personnel's reports, but reports from patients can also contribute to the knowledge of such occurrences. This study aimed to analyse the adverse events reported by dental personnel and patients in public dental service (PDS) in a Swedish county. The PDS has an electronic system for reporting and processing adverse events and, in addition, patients can report shortcomings, as regards to reception and treatment, to a patient committee or to an insurance company. The study material consisted of all adverse events reported in 2010 and 2011, including 273 events reported by dental personnel, 53 events reported by patients to the insurance company and 53 events reported by patients to the patient committee. Data concerning patients' age and gender, the nature, severity and cause of the event and the dental personnel's age gender and profession were collected and analysed. Furthermore the records describing the dental personnel's reports from 2011 were studied to investigate if the event had been documented and the patient informed. Age groups 0 to 9 and 20 to 39 years were underrepresented while those between the ages 10 to 19 and 60 to 69 years were overrepresented in dental personnel's reports. Among young patients delayed diagnosis and therapy dominated and among patients over 20 years the most frequent reports dealt with inadequate treatments, especially endodontic treatments. In 29% of the events there was no documentation of the adverse event in the records and 49% of cases had no report about patient information. The majority of the reports from dental personnel were made by dentists (69%). Reporting adverse events can be seen as a reactive way of working with patient safety, but knowledge about frequencies and causes of incidents is the basis of proactive patient safety work.
不良事件会给医疗保健带来痛苦并增加成本。记录不良事件的主要方式是通过牙科人员的报告，但患者的报告也有助于了解此类事件。本研究旨在分析瑞典一个县公共牙科服务（PDS）中牙科人员和患者报告的不良事件。PDS有一个用于报告和处理不良事件的电子系统，此外，患者可以就接待和治疗方面的不足向患者委员会或保险公司报告。研究材料包括2010年和2011年报告的所有不良事件，其中包括牙科人员报告的273起事件、患者向保险公司报告的53起事件以及患者向患者委员会报告的53起事件。收集并分析了有关患者年龄和性别、事件的性质、严重程度和原因以及牙科人员年龄、性别和职业的数据。此外，还研究了2011年描述牙科人员报告的记录，以调查事件是否已记录在案以及是否已通知患者。在牙科人员的报告中，0至9岁和20至39岁年龄组的比例偏低，而10至19岁和60至69岁年龄组的比例偏高。在年轻患者中，延迟诊断和治疗占主导地位，而在20岁以上的患者中，最常见的报告涉及治疗不足，尤其是牙髓治疗。在29%的事件中，记录中没有不良事件的记录，49%的病例没有关于患者信息的报告。牙科人员的报告大多由牙医做出（69%）。报告不良事件可被视为一种保障患者安全的被动工作方式，但了解事件的频率和原因是主动开展患者安全工作的基础。
