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医生事件报告对组织透明度的意义及患者安全的驱动因素。

Significance of incident reports by medical doctors for organizational transparency and driving forces for patient safety.

作者信息

Fukami Tatsuya, Uemura Masakazu, Nagao Yoshimasa

机构信息

Department of Patient Safety, Nagoya University Hospital, Nagoya, Japan.

出版信息

Patient Saf Surg. 2020 Apr 16;14:13. doi: 10.1186/s13037-020-00240-y. eCollection 2020.

DOI:10.1186/s13037-020-00240-y
PMID:32322306
原文链接:https://pmc.ncbi.nlm.nih.gov/articles/PMC7164346/
Abstract

BACKGROUND

Incident reporting is an effective strategy used to enhance patient safety and quality improvement in healthcare. An incident is an event that could eventually result in harm to a patient. The aim of this study is to re-evaluate the importance of reporting by medical doctors to improve quality in healthcare and patient safety.

METHODS

We conducted a retrospective analysis of the reported incidents registered in our institutional database from April 1st 2015 to March 31st 2019, classified according to eight variables proposed by the National University Hospital Council of Japan, to determine the type of incidents and their potential harm to patients.

RESULTS

Registered reports totalled 43,775, approximately 8% of which arise annually from medical doctors in clinical departments. Incidents with higher impact on patients have significantly increased the rate of reporting by medical doctors. The most frequent types of report overall concerned medication incidents, followed by infusion lines, drainage-tube devices, cure, examination, and treatment outside the operating room. The most frequent reports by medical doctors involved operation-related incidents, followed by cure, examination, treatment outside the operation room, and medications.

CONCLUSION

Reporting by medical doctors reflects the organizational transparency and the driving forces behind patient safety and quality improvement in healthcare. Efforts toward seamless improvement in patient safety and quality at our hospital continue apace.

摘要

背景

事件报告是一种用于提高医疗保健中患者安全和质量改进的有效策略。事件是指最终可能对患者造成伤害的事件。本研究的目的是重新评估医生报告对于改善医疗保健质量和患者安全的重要性。

方法

我们对2015年4月1日至2019年3月31日在我们机构数据库中登记的报告事件进行了回顾性分析,这些事件根据日本国立大学医院理事会提出的八个变量进行分类,以确定事件类型及其对患者的潜在危害。

结果

登记报告总数为43775份,其中约8%每年由临床科室的医生上报。对患者影响较大的事件显著提高了医生的报告率。总体上最常见的报告类型涉及用药事件,其次是输液管、引流管装置、治疗、检查以及手术室以外的治疗。医生最常报告的事件涉及手术相关事件,其次是治疗、检查、手术室以外的治疗以及用药。

结论

医生报告反映了医疗保健中患者安全和质量改进背后的组织透明度和驱动力。我们医院在患者安全和质量方面持续不断地努力改进。

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