From the Korea Institute for Healthcare Accreditation, Seoul.
Department of Nursing Management, College of Nursing Science, Kyung Hee University, Seoul, Republic of Korea.
J Patient Saf. 2022 Aug 1;18(5):382-388. doi: 10.1097/PTS.0000000000000944.
In 2019, the Korean National Patient Safety Incidents Inquiry was conducted in the Republic of Korea to identify the national-level incidence of adverse events. This study determined the incidence and detailed the characteristics of adverse events at 15 regional public hospitals in the Republic of Korea.
Medical records data of 500 randomly selected patients (discharged in 2016) were extracted from each of the 15 studied hospitals and reviewed in 3 stages. First, for each hospital, 2 nurses independently reviewed the medical records, using 41 screening criteria. Second, 2 physicians independently reviewed the records of those patients with at least 1 screening criterion from the first stage for adverse events occurrence and their characteristics. Third, a 9-member committee conducted a final review and compiled the final adverse event report.
Among 7500 patients, 4159 (55.5%) had at least 1 screening criterion; 745 (9.9%) experienced 901 adverse events (incidence, 12.0%). By type of institution, adverse event incidence varied widely from 1.2% to 45.6%. In 1032 adverse events, the majority (33.5%) were "patient care-related." By severity, the majority (638; 70.8%) were temporary, requiring intervention, whereas 38 (4.2%) resulted in death. The preventability score was high for "patient care-related" and "diagnosis-related" adverse events. Duration of hospitalization was extended for 463 (44.9%) adverse events, with "diagnosis-related" (30.8%) and "surgery/procedural-related" (30.1%) types extended by at least 21 days.
A review of medical records aids in identifying adverse events in medical institutions with varying characteristics, thus helping prioritize interventions to reduce their incidence.
2019 年，韩国在全国范围内开展了国家患者安全事件调查，以确定不良事件的全国发生率。本研究旨在确定韩国 15 家地区公立医院的不良事件发生率，并详细描述其特征。
从研究的 15 家医院中，每个医院随机抽取 500 名（2016 年出院）患者的病历数据，分 3 个阶段进行审查。首先，每个医院由 2 名护士使用 41 项筛查标准，对病历进行独立审查。其次，对于第一阶段至少有 1 项筛查标准的患者，由 2 名医生对其不良事件的发生及其特征进行独立审查。最后，由 9 人委员会进行最终审查，并编写最终的不良事件报告。
在 7500 名患者中，有 4159 名（55.5%）至少有 1 项筛查标准；745 名（9.9%）发生 901 起不良事件（发生率为 12.0%）。按机构类型划分，不良事件发生率差异很大，从 1.2%到 45.6%不等。在 1032 起不良事件中，大多数（33.5%）是“与患者护理相关”。按严重程度划分，大多数（638 例；70.8%）为暂时需要干预，而 38 例（4.2%）导致死亡。“与患者护理相关”和“与诊断相关”的不良事件的可预防评分较高。463 例（44.9%）不良事件延长了住院时间，其中“与诊断相关”（30.8%）和“手术/程序相关”（30.1%）类型至少延长了 21 天。
对病历的审查有助于发现具有不同特征的医疗机构中的不良事件，从而有助于确定干预措施的优先顺序，以降低其发生率。
