From the Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School.
Lawrence Center for Quality and Safety, Massachusetts General Hospital and Massachusetts General Physicians' Organization.
J Patient Saf. 2019 Dec;15(4):e60-e63. doi: 10.1097/PTS.0000000000000399.
Incident reporting is a recognized tool for healthcare quality improvement. These systems, which aim to capture near-misses and harm events, enable organizations to gather critical information about failure modes and design mitigation strategies. Although many hospitals have employed these systems, little is known about safety themes in emergency medicine incident reporting. Our objective was to systematically analyze and thematically code 1 year of incident reports.
A mixed-methods analysis was performed on 1 year of safety reporting data from a large, urban tertiary-care emergency department using a modified grounded theory approach.
Between January 1 and December 31, 2015, there were 108,436 emergency department visits. During this time, 750 incident reports were filed. Twenty-nine themes were used to code the reports, with 744 codes applied. The most common themes were related to delays (138/750, 18.4%), medication safety (136/750, 18.1%), and failures in communication (110/750, 14.7%). A total of 48.8% (366/750) of reports were submitted by nurses.
The most prominent themes during 1 year of incident reports were related to medication safety, delays, and communication. Relative to hospital-wide reporting patterns, a higher proportion of reports were submitted by physicians. Despite this, overall incident reporting remains low, and more is needed to engage physicians in reporting.
事件报告是医疗质量改进的一种公认工具。这些旨在捕捉险些发生的和已发生的伤害事件的系统，使组织能够收集关于失效模式的关键信息并设计减轻策略。尽管许多医院已经采用了这些系统，但对于急诊医学事件报告中的安全主题却知之甚少。我们的目的是系统地分析和主题编码 1 年的事件报告。
使用改进的扎根理论方法，对一家大型城市三级急诊部门的 1 年安全报告数据进行混合方法分析。
2015 年 1 月 1 日至 12 月 31 日期间，急诊部就诊患者 108436 例。在此期间，共提交了 750 份事件报告。报告使用 29 个主题进行编码，应用了 744 个代码。最常见的主题是与延迟（138/750，18.4%）、用药安全（136/750，18.1%）和沟通失败（110/750，14.7%）有关。共有 48.8%（366/750）的报告由护士提交。
在 1 年的事件报告中，最突出的主题与用药安全、延迟和沟通有关。与全院报告模式相比，更多的报告是由医生提交的。尽管如此，整体事件报告仍然很低，需要采取更多措施促使医生参与报告。
