Center for Quality Management, Shin Kong Wu Ho-Su Memorial Hospital, No. 95, Wenchang Rd., Shilin Dist., Taipei City 111, Taipei, Taiwan.
Department of Pharmacy, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan.
Sci Rep. 2024 Nov 6;14(1):26905. doi: 10.1038/s41598-024-78661-3.
Underreporting of adverse events in healthcare systems is a global concern. This study aims to address the underreporting of adverse events (AE) by implementing a TRIZ-based model to identify and overcome barriers to reporting, thus filling gaps in current reporting practices and improving incident recognition. A TRIZ (Theory of Inventive Problem Solving) approach was adopted, integrating with SERVQUAL methodologies to design interventions. Preintervention and postintervention surveys were conducted to evaluate changes in the recognition of adverse events and barriers to reporting. Statistical analyses were performed to assess the effectiveness of the interventions. Recognition improved and barriers to reporting AEs significantly decreased. Monthly reported cases rose from 33.7 to 50.3 (p = 0.000), demonstrating the effectiveness of the TRIZ-based interventions. Implementing a TRIZ-based model significantly improved adverse event reporting by enhancing the recognition of reportable events and overcoming identified barriers. Future research should explore the long-term sustainability of these interventions and their broader applicability in diverse healthcare settings.
医疗系统中不良事件报告不足是一个全球性问题。本研究旨在通过实施基于 TRIZ 的模型来解决不良事件报告不足的问题，从而发现和克服报告障碍，填补当前报告实践中的空白，并提高事件识别能力。采用了 TRIZ（发明问题解决理论）方法，并结合 SERVQUAL 方法设计干预措施。在干预前后进行了调查，以评估对不良事件识别和报告障碍的变化。进行了统计分析以评估干预措施的效果。识别能力得到提高，报告不良事件的障碍明显减少。每月报告的病例从 33.7 例增加到 50.3 例（p=0.000），表明基于 TRIZ 的干预措施是有效的。实施基于 TRIZ 的模型通过增强可报告事件的识别和克服已确定的障碍，显著提高了不良事件报告。未来的研究应探讨这些干预措施的长期可持续性及其在不同医疗保健环境中的更广泛适用性。
