Toyabe Shin-ichi
Niigata University Crisis Management Office, Niigata University Hospital.
Glob J Health Sci. 2015 Jun 25;8(3):17-25. doi: 10.5539/gjhs.v8n3p17.
An incident reporting system is the most commonly used method to identify patient safety incidents in a hospital. However, non-reporting of incidents for various reasons is a serious problem. We studied the rate of inpatient falls that were not reported in an incident reporting system but were recorded in medical charts and we evaluated characteristics of those falls by comparing with the falls reported in incident reports in a Japanese acute care hospital setting. Falls recorded in medical charts were detected by using a text mining method followed by a manual chart review. About 25% of the recorded falls were not reported in incident reports. Male patients, first fall, long lag time until recording, no witness at the time of the fall and physician profession were shown to be significant factors associated with non-reporting. Our results show that the rate of non-reporting of inpatient falls in a Japanese acute care hospital is compable to that shown in previous studies in other conutries and that the same barriers to incident reporting as those found in previous studies exist in the medical staff.
事件报告系统是医院识别患者安全事件最常用的方法。然而,由于各种原因未报告事件是一个严重问题。我们研究了在事件报告系统中未报告但记录在病历中的住院患者跌倒发生率,并通过与日本一家急性护理医院环境中事件报告中报告的跌倒进行比较,评估了这些跌倒的特征。通过文本挖掘方法检测病历中记录的跌倒,然后进行人工病历审查。约25%的记录跌倒未在事件报告中报告。男性患者、首次跌倒、记录前延迟时间长、跌倒时无目击者以及医生职业被证明是与未报告相关的重要因素。我们的结果表明,日本急性护理医院住院患者跌倒的未报告率与其他国家先前研究中显示的未报告率相当,并且医务人员中存在与先前研究中发现的相同的事件报告障碍。