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[分析德国大学医院事件报告系统的实施与使用情况:横断面在线调查结果]

[Analyzing the implementation and use of incident reporting systems in German university hospitals: Results of a cross-sectional online survey].

作者信息

Hölzing Carlos Ramon, Meynhardt Charlotte, Meybohm Patrick, Happel Oliver

机构信息

Universitätsklinikum Würzburg, Klinik und Poliklinik für Anästhesiologie, Intensivmedizin, Notfallmedizin und Schmerztherapie, Würzburg, Deutschland.

Universitätsklinikum Würzburg, Klinik und Poliklinik für Anästhesiologie, Intensivmedizin, Notfallmedizin und Schmerztherapie, Würzburg, Deutschland.

出版信息

Z Evid Fortbild Qual Gesundhwes. 2025 Jun;195:28-35. doi: 10.1016/j.zefq.2025.03.010. Epub 2025 May 2.

Abstract

BACKGROUND

Critical incident reporting systems (CIRS) are a central component for ensuring patient safety and an essential tool in risk management at German university hospitals. Despite their widespread use, there are still considerable challenges with regard to their practical application and effectiveness. The aim of this study is to analyze the dissemination and use of such systems and the associated barriers in order to identify potential for optimization.

METHODS

A cross-sectional online survey was conducted among all German university hospitals (n = 38) between August and September 2024. Both structural and process-related variables were recorded, supplemented by selected aspects of the WHO CIRS self-assessment. The data was analyzed descriptively using SPSS® Statistics Version 29, supported by graphical representation using GrapPad Prism 9®.

RESULTS

Of the 38 university hospitals contacted, 14 participated (36.8%). All participating university hospitals use internal critical incident reporting systems. 92.9% forward reports to cross-institutional systems, with 92.3% of the university hospitals forwarding less than 10% of the reports. Most university hospitals (11) evaluate ≥ 90% of incoming reports, ten hospitals do not use standardized analysis specifications. Feedback to reporting persons is provided in eight out of 14 university hospitals. The WHO self-assessment showed deficits in the implementation of personalized feedback and clear criteria.

CONCLUSION

Despite the widespread use of critical incident reporting systems, the results reveal a clear optimization potential in the standardization of analysis processes, the prompt processing of reports and feedback mechanisms. The low transfer of reports to cross-institutional systems indicates structural and organizational barriers that need to be addressed. These findings provide important insights to support the further development of incident reporting systems and thus improve both patient safety and risk management.

摘要

背景

重大事件报告系统(CIRS)是确保患者安全的核心组成部分,也是德国大学医院风险管理的重要工具。尽管其广泛应用,但在实际应用和有效性方面仍存在相当大的挑战。本研究的目的是分析此类系统的传播和使用情况以及相关障碍,以确定优化潜力。

方法

2024年8月至9月期间,对德国所有38所大学医院进行了横断面在线调查。记录了结构和流程相关变量,并辅以世界卫生组织CIRS自我评估的选定方面。使用SPSS® Statistics 29版对数据进行描述性分析,并借助GrapPad Prism 9®进行图形表示。

结果

在联系的38所大学医院中,14所参与(36.8%)。所有参与的大学医院都使用内部重大事件报告系统。92.9%的医院将报告转发至跨机构系统,其中92.3%的大学医院转发的报告少于10%。大多数大学医院(11所)评估了≥90%的收到的报告,10所医院未使用标准化分析规范。14所大学医院中有8所向报告人提供了反馈。世界卫生组织的自我评估显示在个性化反馈和明确标准的实施方面存在不足。

结论

尽管重大事件报告系统广泛使用,但结果显示在分析流程标准化、报告及时处理和反馈机制方面存在明显的优化潜力。报告向跨机构系统的低传输率表明存在需要解决的结构和组织障碍。这些发现为支持事件报告系统的进一步发展提供了重要见解,从而提高患者安全和风险管理水平。

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