Hotton Emily, Jordan Lesley, Peden Carol
Royal United Hospital Bath, UK.
BMJ Qual Improv Rep. 2014 Nov 3;3(1). doi: 10.1136/bmjquality.u202381.w2481. eCollection 2014.
To ensure systems in hospitals improve to make patient care safer, learning must occur when things go wrong. Incident reporting is one of the commonest mechanisms used to learn from harm events and near misses. Only a relatively small number of incidents that occur are actually reported and different groups of staff have different rates of reporting. Nationally, junior doctors are low reporters of incidents, a finding supported by our local data. We set out to explore the culture and awareness around incident reporting among our junior doctors, and to improve the incident reporting rate within this important staff group. In order to achieve this we undertook a number of work programmes focused on junior doctors, including: assessment of their knowledge, confidence and understanding of incident reporting, education on how and why to report incidents with a focus on reporting on clinical themes during a specific time period, and evaluation of the experience of those doctors who reported incidents. Junior doctors were asked to focus on incident reporting during a one week period. Before and after this focussed week, they were invited to complete a questionnaire exploring their confidence about what an incident was and how to report. Prior to "Incident Reporting Week", on average only two reports were submitted a month by junior doctors compared with an average of 15 per month following the education and awareness week. This project highlights the fact that using a focussed reporting period and/or specific clinical themes as an education tool can benefit a hospital by promoting awareness of incidents and by increasing incident reporting rates. This can only assist in improving hospital systems, and ultimately increase patient safety.
为确保医院系统得到改进以使患者护理更安全，必须在出现问题时进行学习。事件报告是从伤害事件和未遂事故中吸取教训最常用的机制之一。实际报告的事件数量相对较少，而且不同工作人员群体的报告率也不同。在全国范围内，初级医生报告事件的比例较低，我们当地的数据也支持这一发现。我们着手探索初级医生对事件报告的文化和意识，并提高这一重要工作人员群体的事件报告率。为了实现这一目标，我们开展了一些针对初级医生的工作计划，包括：评估他们对事件报告的知识、信心和理解，开展关于如何以及为何报告事件的教育，重点是在特定时间段内报告临床主题，并评估报告事件的医生的经验。我们要求初级医生在一周内专注于事件报告。在这个重点关注周之前和之后，我们邀请他们填写一份问卷，以了解他们对什么是事件以及如何报告的信心。在“事件报告周”之前，初级医生平均每月仅提交两份报告，而在开展教育和提高意识周之后，这一数字平均为每月15份。该项目凸显了这样一个事实，即利用重点报告期和/或特定临床主题作为教育工具，可以通过提高对事件的认识和增加事件报告率，使医院受益。这只能有助于改进医院系统，并最终提高患者安全。
