University of Utah Health School of Medicine, Department of Surgery, Salt Lake City, UT, USA.
University of Utah Health School of Medicine, Salt Lake City, UT, USA.
Am J Surg. 2020 Jan;219(1):21-26. doi: 10.1016/j.amjsurg.2019.05.012. Epub 2019 May 25.
Patient safety event reporting systems are a mainstay in non-punitive reporting of near misses and adverse events. We hypothesized that an upgraded reporting system that included the ability to report positive behaviors would increase behavioral reports in the perioperative environment.
We performed a retrospective assessment of prospectively collected reports from the Patient Safety Net (PSN) event reporting system (2/2010-2/2015) and the RL Solutions RL6 system (8/2015-4/2018).
Under the PSN system, 0.8 behavioral events per quarter were submitted, compared to 7.4 behavioral events per quarter with the RL6 system. The average length of reports increased from 61 to 185 words. Reports were most often submitted by nursing staff (66%), and about attending physicians (36%). 22% of reports under the RL6 system were positive; 46% of these positive reports were about physicians.
After implementation of an upgraded reporting system that includes an option for positive reporting, the number and length of reports increased. We believe that a robust reporting system has contributed to a culture of safety at our institution.
患者安全事件报告系统是对近误和不良事件进行非惩罚性报告的主要手段。我们假设，一个升级的报告系统，包括报告积极行为的能力，将增加围手术期环境中的行为报告。
我们对前瞻性收集的患者安全网（PSN）事件报告系统（2010 年 2 月至 2015 年 2 月）和 RL 解决方案 RL6 系统（2015 年 8 月至 2018 年 4 月）中的报告进行了回顾性评估。
在 PSN 系统下，每季度提交 0.8 项行为事件，而在 RL6 系统下每季度提交 7.4 项行为事件。报告的平均长度从 61 个单词增加到 185 个单词。报告主要由护理人员（66%）提交，其次是主治医生（36%）。RL6 系统下 22%的报告是积极的；其中 46%的积极报告与医生有关。
在实施了一个升级的报告系统后，包括报告积极事件的选项，报告的数量和长度都有所增加。我们相信，一个强大的报告系统有助于我们机构建立安全文化。
