Jämsä Juho Olavi, Palojoki Sari Hannele, Lehtonen Lasse, Tapper Anna-Maija
Finnair, Finland.
Helsinki and Uusimaa University Hospital District, Finland.
J Healthc Risk Manag. 2018 Oct;38(2):27-35. doi: 10.1002/jhrm.21310. Epub 2018 Jan 10.
To determine if and in what ways serious patient safety incidents differ from nonserious patient safety incidents.
Statistical analysis was performed on patient safety incident reports that were reported in 2015 in Finland's largest hospital district (Helsinki and Uusimaa, HUS). Reports were divided into two groups: nonserious incidents and serious incidents. Differences between groups were studied from several types of categorically divided information.
Of the total number of reports (15,863), 1% were serious incidents (175). Serious and nonserious incidents differed significantly from each other. Serious incidents concerning laboratory, imaging, or medical equipment were more common. On the other hand, incidents concerning medication, infusion, and blood transfusion were less frequent. In serious incidents, the proportion of doctors reporting was greater, and contributing factors were better recognized, the most common being working of procedures.
In the future, special attention should be given to the particular aspects of serious patient safety incidents, such as safe use of medical equipment, training, and handling of procedures. Root cause analysis is an effective way to handle serious incidents and enables the prevention of their reoccurrence. However, a systematic follow-up of the root cause analysis should be developed.
确定严重患者安全事件与非严重患者安全事件是否存在差异以及在哪些方面存在差异。
对芬兰最大医院区（赫尔辛基和新地区，HUS）2015年报告的患者安全事件报告进行统计分析。报告分为两组：非严重事件和严重事件。从几类分类信息中研究两组之间的差异。
在报告总数（15863份）中，1%为严重事件（175份）。严重事件和非严重事件彼此有显著差异。涉及实验室、影像或医疗设备的严重事件更为常见。另一方面，涉及药物、输液和输血的事件较少。在严重事件中，医生报告的比例更大，促成因素得到更好的识别，最常见的是操作流程。
未来，应特别关注严重患者安全事件的特定方面，如医疗设备的安全使用、培训和操作流程的处理。根本原因分析是处理严重事件的有效方法，能够预防其再次发生。然而，应建立对根本原因分析的系统跟踪。
