Silpasuwan Pimpan, Viwatwongasame Chukeat, Kongtip Pornpimol, Bandhukul Adul, Omas Thida, Woskie Susan
Department of Public Health Nursing, Faculty of Public Health, Mahidol University, Bangkok, Thailand.
Department of Biostatistics, Faculty of Public Health, Mahidol University, Bangkok, Thailand.
Arch Med (Oviedo). 2017;9(2). doi: 10.21767/1989-5216.1000202. Epub 2017 Mar 27.
Latent errors in an incident reporting system pose threats to accident and near-miss prevention in hospitals. The aims of this study were to gain insight into the incident reporting system by exploring and investigating the refinement of unreported and under-reported (near-miss) patterns and by estimating under-reported annual hospital accidents over three months in one hospital.
Sequential mixed-method research was undertaken using both qualitative and quantitative approaches. 120 health care providers were selected from 13 departments of a selected study hospital. Self-reported questionnaires, information from annual reports and focus group interviews among stakeholders were employed. Based on a quantitative mixed-model approach, estimation of lost cases from near-miss incidents was made.
In 2015, 20% of accidents had been reported to the hospital center while under-reported accidents and near-miss incidents by self-report over 3 months equaled 18% and 25.9%, respectively. Recent trends were positive, driven by changing values about incident reporting. However, confusion and fear still remain among practitioners about near-miss reporting due to old beliefs. This study confirms that incident reporting needs improvement so that there is an enhanced organizational culture of safety, raised awareness for individual reporting, and recovery of lost cases using mixed-model estimation of near-misses.
事件报告系统中的潜在错误对医院的事故预防和未遂事故预防构成威胁。本研究的目的是通过探索和调查未报告和报告不足（未遂事故）模式的改进情况，并估计一家医院三个月内每年未报告的医院事故数量，来深入了解事件报告系统。
采用定性和定量相结合的序贯混合方法进行研究。从选定研究医院的13个科室中选取了120名医疗服务提供者。采用自我报告问卷、年度报告信息以及利益相关者焦点小组访谈等方式。基于定量混合模型方法，对未遂事故中的漏报病例进行了估计。
2015年，20%的事故已上报至医院中心，而通过自我报告得出的三个月内未报告事故和未遂事故分别为18%和25.9%。由于对事件报告的价值观发生变化，近期趋势呈积极态势。然而，由于旧观念作祟，从业者对未遂事故报告仍存在困惑和恐惧。本研究证实，事件报告需要改进，以便增强安全的组织文化，提高个人报告意识，并通过对未遂事故的混合模型估计来找回漏报病例。
