Department of Medicine, University of Calgary, Calgary, Alberta, Canada
Department of Medicine, University of Alberta, Edmonton, Alberta, Canada.
BMJ Open Qual. 2022 Oct;11(4). doi: 10.1136/bmjoq-2022-001945.
Reports of adverse events and near-misses provide the opportunity to learn about latent (systems) errors. However, voluntary incident reporting systems are underused by physicians. While reports submitted by nursing staff relate to common hazards such as medication administration or falls, physicians have broader exposure to patients' entire hospital journey. Reports by physicians have the potential to uncover more serious errors that could span multiple departments and layers of personnel. Organisational safety culture thrives when all staff are represented and feel empowered to share safety concerns.At the South Health Campus (SHC) Hospital in Calgary, Alberta, Canada, the baseline proportion of physician-submitted reports within our site's Reporting and Learning System (RLS) from July 2013 to December 2016 was 1.12%. We implemented an intervention to double the proportion of physician-submitted RLS reports, using quality improvement methods.Focus groups identified lack of experience with the RLS system, lack of feedback or closure after an RLS submission, and apprehensions about disclosing the incident to the affected patient as barriers to physician submission. Accordingly, the intervention involved direct responses from physician leadership to each physician-submitted RLS report, multimedia demonstrations of efficient RLS submission to physician groups and medical learners, and linkage to materials on safe disclosures. Effectiveness was assessed using a controlled before-and-after design, comparing SHC with the rest of Calgary and with the rest of Alberta.Following the intervention, the proportion of RLS reports that were physician submitted increased to 2.65% (OR 2.42 [95% CI 1.96 to 3.02], p<0.001), sustained over the following 4 years. While an increase was observed for the rest of Calgary, it was smaller (OR 1.27 [1.15 to 1.40], p<0.001). A decrease in the odds of physician submission was observed for the rest of Alberta. Differences between sites were significant (p<0.001).Overall, we found that physician-submitted incident reports can be increased and sustained over time if submitters receive personalised feedback by a physician safety leader. At our site, reports submitted by physicians have been valuable in uncovering complex systems issues that may not have been readily apparent.
不良事件和险兆事件报告为了解潜在（系统）错误提供了机会。然而，医生对自愿事件报告系统的使用不足。虽然护理人员提交的报告涉及药物管理或跌倒等常见危害，但医生对患者整个住院过程的接触更为广泛。医生提交的报告有可能发现更严重的错误，这些错误可能跨越多个部门和多个人员层次。当所有员工都有代表并有权分享安全问题时，组织的安全文化就会蓬勃发展。在加拿大阿尔伯塔省卡尔加里的南健康校园（SHC）医院，我们从 2013 年 7 月到 2016 年 12 月在我们的报告和学习系统（RLS）中收到的医生提交报告的比例为 1.12%。我们使用质量改进方法实施了一项干预措施，将医生提交的 RLS 报告比例提高一倍。焦点小组确定缺乏对 RLS 系统的经验、RLS 提交后缺乏反馈或结束，以及对向受影响患者披露事件的担忧是医生提交的障碍。因此，干预措施包括医生领导层对每个医生提交的 RLS 报告的直接回应、向医生群体和医学生多媒体演示高效的 RLS 提交，以及与安全披露相关材料的链接。使用对照前后设计评估有效性，将 SHC 与卡尔加里的其他地区和阿尔伯塔省的其他地区进行比较。干预措施实施后，医生提交的 RLS 报告比例增加到 2.65%（OR 2.42 [95%CI 1.96 至 3.02]，p<0.001），并在随后的 4 年内保持稳定。虽然卡尔加里的其他地区也有所增加，但幅度较小（OR 1.27 [1.15 至 1.40]，p<0.001）。阿尔伯塔省其他地区医生提交的可能性下降。各站点之间存在显著差异（p<0.001）。总的来说，如果提交人通过医生安全领导者收到个性化反馈，医生提交的事件报告可以增加并持续一段时间。在我们的网站上，医生提交的报告在发现可能不太明显的复杂系统问题方面非常有价值。
