Saravi Benyamin Mohseni, Mardanshahi Alireza, Ranjbar Mansour, Siamian Hasan, Azar Masoud Shayeste, Asghari Zolikah, Motamed Nima
Health information management, Mazandaran University of Medical Sciences, Sari, Iran.
Nuclear Medicine Department. Mazandaran University of Medical Sciences, Sari, Iran.
Mater Sociomed. 2015 Feb;27(1):31-4. doi: 10.5455/msm.2014.27.31-34. Epub 2015 Feb 21.
Health care organizations are highly specialized and complex. Thus we may expect the adverse events will inevitably occur. Building a medical error reporting system to analyze the reported preventable adverse events and learn from their results can help to prevent the repeat of these events. The medical errors which were reported to the Clinical Governance's office of Mazandaran University of Medical Sciences (MazUMS) in years 2011-2012 were analyzed.
This is a descriptive retrospective study in which 18 public hospitals were participated. The instrument of data collection was checklist that was designed by the Ministry of Health of Iran. Variables were type of hospital, unit of hospital, season, severity of event and type of error. The data were analyzed with SPSS software.
Of 317966 admissions 182 cases, about 0.06%, medical error reported of which most of the reports (%51.6) were from non- teaching hospitals. Among various units of hospital, the highest frequency of medical error was related to surgical unit (%42.3). The frequency of medical error according to the type of error was also evaluated of which the highest frequency was related to inappropriate and no care (totally 37%) and medication error 28%. We also analyzed the data with respect to the effect of the error on a patient of which the highest frequency was related to minor effect (44.5%).
The results showed that a wide variety of errors. Encourage and revision of the reporting process will be result to know more data for prevention of them.
医疗保健机构高度专业化且复杂。因此，我们可以预期不良事件将不可避免地发生。建立一个医疗差错报告系统，分析报告的可预防不良事件并从其结果中吸取教训，有助于防止这些事件再次发生。对2011 - 2012年期间向马赞德兰医科大学（MazUMS）临床治理办公室报告的医疗差错进行了分析。
这是一项描述性回顾性研究，有18家公立医院参与。数据收集工具是由伊朗卫生部设计的检查表。变量包括医院类型、医院科室、季节、事件严重程度和差错类型。数据用SPSS软件进行分析。
在317966例住院病例中，报告了182例医疗差错，约占0.06%，其中大部分报告（51.6%）来自非教学医院。在医院的各个科室中，医疗差错发生率最高的是外科科室（42.3%）。还根据差错类型评估了医疗差错发生率，其中发生率最高的是不适当和无护理（总计37%）以及用药差错（28%）。我们还分析了差错对患者影响的数据，其中发生率最高的是轻微影响（44.5%）。
结果表明存在各种各样的差错。鼓励并修订报告流程将有助于获取更多数据以预防这些差错。
