Wagner Cordula, Merten Hanneke, Zwaan Laura, Lubberding Sanne, Timmermans Danielle, Smits Marleen
NIVEL, Netherlands Institute for Health Services Research, Utrecht, The Netherlands Department of Public and Occupational Health, EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands.
Department of Public and Occupational Health, EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands.
BMJ Open. 2016 Jun 21;6(6):e011277. doi: 10.1136/bmjopen-2016-011277.
To minimise adverse events in healthcare, various large-scale incident reporting and learning systems have been developed worldwide. Nevertheless, learning from patient safety incidents is going slowly. Local, unit-based reporting systems can help to get faster and more detailed insight into unit-specific safety issues. The aim of our study was to gain insight into types and causes of patient safety incidents in hospital units and to explore differences between unit types.
Prospective observational study.
10 emergency medicine units, 10 internal medicine units and 10 general surgery units in 20 hospitals in the Netherlands participated. Patient safety incidents were reported by healthcare providers. Reports were analysed with root cause analysis. The results were compared between the 3 unit types.
A total of 2028 incidents were reported in an average reporting period of 8 weeks per unit. More than half had some consequences for patients, such as a prolonged hospital stay or longer waiting time, and a small number resulted in patient harm. Significant differences in incident types and causes were found between unit types. Emergency units reported more incidents related to collaboration, whereas surgical and internal medicine units reported more incidents related to medication use. The distribution of root causes of surgical and emergency medicine units showed more mutual similarities than those of internal medicine units.
Comparable incidents and causes have been found in all units, but there were also differences between units and unit types. Unit-based incident reporting gives specific information and therefore makes improvements easier. We conclude that unit-based incident reporting has an added value besides hospital-wide or national reporting systems that already exist in various countries.
为尽量减少医疗保健中的不良事件，全球已开发了各种大规模事件报告和学习系统。然而，从患者安全事件中吸取教训的进展缓慢。基于科室的本地报告系统有助于更快、更详细地深入了解科室特定的安全问题。我们研究的目的是深入了解医院科室患者安全事件的类型和原因，并探讨科室类型之间的差异。
前瞻性观察研究。
荷兰20家医院的10个急诊科、10个内科科室和10个普通外科科室参与了研究。医疗服务提供者报告患者安全事件。采用根本原因分析法对报告进行分析。对三种科室类型的结果进行比较。
每个科室平均8周的报告期内共报告了2028起事件。超过一半的事件对患者产生了一些影响，如住院时间延长或等待时间变长，少数事件导致患者受到伤害。在事件类型和原因方面发现科室类型之间存在显著差异。急诊科报告的与协作相关的事件更多，而外科和内科科室报告的与用药相关的事件更多。外科和急诊科的根本原因分布比内科科室的更为相似。
在所有科室中都发现了类似的事件和原因，但科室之间以及科室类型之间也存在差异。基于科室的事件报告提供了具体信息，因此更容易进行改进。我们得出结论，除了各国现有的全院范围或国家报告系统之外，基于科室的事件报告具有附加价值。
