Harkness Fellow, Commonwealth Fund, Medical School, Australian National University, Canberra, Australian Capital Territory, Australia.
Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.
BMJ Qual Saf. 2016 Feb;25(2):92-9. doi: 10.1136/bmjqs-2015-004405. Epub 2015 Jul 27.
One of the key recommendations of the Institute of Medicine's (IOM) report, To Err is Human, 15 years ago was for greater attention to incident reporting in healthcare, analogous to the role it has played in aviation and other high-risk industries. With the passage of time and maturation of the patient safety field, we conducted semistructured interviews with 11 international patient safety experts with knowledge of the US healthcare and meeting at least one of the following criteria: (1) involved in the development of the IOM's recommendations, (2) responsible for the design and/or implementation of national or regional incident reporting systems, (3) conducted research on patient safety/incident reporting at a national level. Five key challenges emerged to explain why incident reporting has not reached its potential: poor processing of incident reports (triaging, analysis, recommendations), inadequate engagement of doctors, insufficient subsequent visible action, inadequate funding and institutional support of incident reporting systems and inadequate usage of evolving health information technology. Leading patient safety experts acknowledge the current challenges of incident reports. The future of incident reporting lies in targeted incident reporting, effective triaging and robust analysis of the incident reports and meaningful engagement of doctors. Incident reporting must be coupled with visible, sustainable action and linkage of incident reports to the electronic health record. If the healthcare industry wants to learn from its mistakes, miss or near miss events, it will need to take incident reporting as seriously as the health budget.
十五年前，医学研究所（IOM）报告《人非圣贤，孰能无过》的一项关键建议是，在医疗保健领域更多地关注事件报告，类似于其在航空和其他高风险行业中所发挥的作用。随着时间的推移和患者安全领域的成熟，我们对半结构化访谈了 11 名国际患者安全专家进行了访谈，这些专家对美国医疗保健有一定的了解，并且符合以下至少一个标准：（1）参与制定 IOM 的建议，（2）负责国家或地区事件报告系统的设计和/或实施，（3）在国家层面开展患者安全/事件报告研究。出现了五个关键挑战来解释为什么事件报告尚未发挥其潜力：事件报告处理不善（分类、分析、建议）、医生参与度不足、后续明显行动不足、事件报告系统资金和机构支持不足以及不断发展的医疗信息技术使用不足。领先的患者安全专家承认当前事件报告面临的挑战。事件报告的未来在于有针对性的事件报告、有效的分类和对事件报告的稳健分析，以及医生的积极参与。事件报告必须与明显的、可持续的行动以及将事件报告与电子健康记录联系起来。如果医疗保健行业想从错误、失误或险些发生的事件中吸取教训，就需要像重视医疗预算一样重视事件报告。
