Sendlhofer Gerald, Leitgeb Karina, Kober Brigitte, Brunner Gernot, Kamolz Lars-Peter
Stabsstelle Qualitäts- und Risikomanagement, LKH-Univ. Klinikum Graz, Graz, Österreich; Klinische Abteilung für Plastische, Ästhetische und Rekonstruktive Chirurgie, Univ. Klinik für Chirurgie, Medizinische Universität Graz, Graz, Österreich; Research Unit for Safety in Health, Medizinische Universität Graz, Graz, Österreich.
Stabsstelle Qualitäts- und Risikomanagement, LKH-Univ. Klinikum Graz, Graz, Österreich; Research Unit for Safety in Health, Medizinische Universität Graz, Graz, Österreich.
Z Evid Fortbild Qual Gesundhwes. 2016;114:48-57. doi: 10.1016/j.zefq.2016.06.005. Epub 2016 Jul 18.
Critical Incident Reporting Systems (CIRS) are an important tool to identify potential hazards in healthcare. However, in Europe CIR systems are differently used with respect to whether its use is voluntary or mandatory. The aim of the present paper was to describe the development of the recently implemented CIRS in the University Hospital Graz.
In 2012, in a pilot unit CIRS was implemented within an intensive care unit. After evaluating its results, CIRS was then implemented in all organizational units of the University Hospital Graz in 2013. The definition of a CIRS report as well as the processing of CIRS reports was described in a CIRS manual.
On average, 1.6 CIRS reports per week were submitted in the University Hospital Graz. Compared to data from a university hospital in Switzerland (27 CIRS reports per week), it becomes evident that, in general, CIRS is used, but the question arises whether CIRS is commonly known and whether information on the proceeding of CIRS cases is sufficiently transparent.
Overall, the implementation of CIRS is relatively simple, but in order to achieve acceptance and thereby continuous reports, trust and a value-free handling of critical reports is required. Meetings with openly discussed case analysis could help to increase the awareness of CIRS among healthcare professionals. In Europe CIR systems are used in different ways. In Austria, both an academic exchange process on how to use CIRS and a common definition of CIRS reports has so far been lacking. The preparation of a guidance document for Austria is recommended.
医疗不良事件报告系统(CIRS)是识别医疗保健中潜在危害的重要工具。然而,在欧洲,CIRS系统在使用上是自愿还是强制方面存在差异。本文的目的是描述格拉茨大学医院最近实施的CIRS的发展情况。
2012年,在一个试点单位,CIRS在重症监护病房内实施。在评估其结果后,CIRS于2013年在格拉茨大学医院的所有组织单位实施。CIRS报告的定义以及CIRS报告的处理在一份CIRS手册中进行了描述。
在格拉茨大学医院,平均每周提交1.6份CIRS报告。与瑞士一家大学医院的数据(每周27份CIRS报告)相比,可以明显看出,总体而言,CIRS是被使用的,但问题是CIRS是否广为人知,以及CIRS案例的处理信息是否足够透明。
总体而言,CIRS的实施相对简单,但为了获得认可并从而实现持续报告,需要信任以及对关键报告进行无价值判断的处理方式。进行公开讨论案例分析的会议有助于提高医疗专业人员对CIRS的认识。在欧洲,CIRS系统的使用方式各不相同。在奥地利,到目前为止,既缺乏关于如何使用CIRS的学术交流过程,也缺乏CIRS报告的统一定义。建议为奥地利编写一份指导文件。