Odegård S
Socialstyrelsen, Stockholm.
Nord Med. 1996 Dec;111(10):352-5.
The Swedish system concerning injuries in the health care sector has its origin in an incident 1936 at the Maria hospital in Stockholm. Four patients died following injection of mercury oxycyanide instead of a local anaesthetic. The first law in 1937 focused on disciplinary actions with prescribed duties to report patient injuries both to the National Board of Health and Welfare and the local police. The regulations, often called lex Maria, have changed during the past 60 years. It is now stressed, beside the punitive aspects, that also incidents not causing injuries should be reported, that organisational factors should be considered in the evaluations of incidents and that a main aspect of the system is prevention.
瑞典医疗保健领域的伤害报告系统起源于1936年斯德哥尔摩玛丽亚医院发生的一起事件。四名患者在注射了氰氧化汞而非局部麻醉剂后死亡。1937年的第一部法律侧重于纪律处分，规定有义务向国家卫生和福利委员会以及当地警方报告患者受到的伤害。这些规定，通常被称为《玛丽亚法》，在过去60年里有所变化。现在强调，除了惩罚方面，未造成伤害的事件也应报告，在事件评估中应考虑组织因素，并且该系统的一个主要方面是预防。
