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伊朗一家大型医院基于网络的错误报告监测系统评估

Evaluation of a Web-based Error Reporting Surveillance System in a Large Iranian Hospital.

作者信息

Askarian Mehrdad, Ghoreishi Mahboobeh, Akbari Haghighinejad Hourvash, Palenik Charles John, Ghodsi Maryam

机构信息

Medicinal and Natural Products Chemistry Research Center, Department of Community Medicine, Shiraz University of Medical Sciences, Shiraz, IR Iran.

Student Research Committee, Department of Community Medicine, Shiraz University of Medical Sciences, Shiraz, IR Iran.

出版信息

Arch Iran Med. 2017 Aug;20(8):511-517.

Abstract

BACKGROUND

Proper reporting of medical errors helps healthcare providers learn from adverse incidents and improve patient safety. A well-designed and functioning confidential reporting system is an essential component to this process. There are many error reporting methods; however, web-based systems are often preferred because they can provide; comprehensive and more easily analyzed information. This study addresses the use of a web-based error reporting system.

METHODS

This interventional study involved the application of an in-house designed "voluntary web-based medical error reporting system." The system has been used since July 2014 in Nemazee Hospital, Shiraz University of Medical Sciences. The rate and severity of errors reported during the year prior and a year after system launch were compared.

RESULTS

The slope of the error report trend line was steep during the first 12 months (B = 105.727, P = 0.00). However, it slowed following launch of the web-based reporting system and was no longer statistically significant (B = 15.27, P = 0.81) by the end of the second year. Most recorded errors were no-harm laboratory types and were due to inattention. Usually, they were reported by nurses and other permanent employees. Most reported errors occurred during morning shifts.

DISCUSSION

Using a standardized web-based error reporting system can be beneficial. This study reports on the performance of an in-house designed reporting system, which appeared to properly detect and analyze medical errors. The system also generated follow-up reports in a timely and accurate manner. Detection of near-miss errors could play a significant role in identifying areas of system defects.

摘要

背景

对医疗差错进行恰当报告有助于医疗服务提供者从不良事件中吸取教训并提高患者安全。一个设计良好且运行正常的保密报告系统是这一过程的重要组成部分。有多种差错报告方法;然而,基于网络的系统通常更受青睐,因为它们能提供全面且更易于分析的信息。本研究探讨了基于网络的差错报告系统的使用情况。

方法

这项干预性研究涉及应用一个内部设计的“基于网络的自愿医疗差错报告系统”。该系统自2014年7月起在设拉子医科大学内马齐医院使用。比较了系统启用前一年和启用后一年报告的差错发生率及严重程度。

结果

在最初的12个月里,差错报告趋势线的斜率很陡(B = 105.727,P = 0.00)。然而,在基于网络的报告系统启用后,斜率放缓,到第二年年底时不再具有统计学意义(B = 15.27,P = 0.81)。记录的大多数差错属于无伤害的实验室类型,且是由于疏忽所致。通常,这些差错是由护士和其他长期雇员报告的。大多数报告的差错发生在早班期间。

讨论

使用标准化的基于网络的差错报告系统可能有益。本研究报告了一个内部设计的报告系统的运行情况,该系统似乎能正确检测和分析医疗差错。该系统还能及时、准确地生成后续报告。对未遂差错的检测在识别系统缺陷领域可能发挥重要作用。

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