以資訊科技建構病人安全事件通報系統——以某區域醫院為例

Institutional Internal Reporting Systems for Patient Safety – A Case Study of a Regional Hospital

通報系統之建立有助於醫護人員了解醫療錯誤可能發生之原因，並透過資訊的分享，使問題盡可能即時性的控制、並獲得解決或改善，更重要的是讓傷害事件降到最低，及從事記得處理中獲得經驗的學習。本文運用一家地區醫院為探討之案例，提出在建置一套病人安全事件通報系統的過程，可以分為四個階段：文件化、合理化、標準化與資訊化。本文的結果顯示，該地區醫院所建構之病人安全內部通報資訊系統，提供有效之通報回饋機制使漸漸透明化，尤其針對異常事件嚴重度評估數小於2分支事件，將進入根本原因分析小組之討論，所以達到通報事件，而且全體員工可以透過該資訊系統之知識分享區，了解事件處理與改善過程。本研究也觀察到病安事件透過資訊系統通報，可以節省書面報表製作以及減少人工傳送時間，相對地提升了事件傳達管理部門時效。另外，更由於通報資訊系統帶來的便利性，及無懲罰的通報制度，在該地區醫院有效地提升員工主動通報意願，已經成功塑造病人安全通報文化。

Internal Reporting Systems (IRS) assist medical professionals in having more information on the possible causes of Medical Adverse Events (MAE). IRS could solve the MAE or help in improving the situations with close to real-time control on the problems via information sharing in the healthcare system. More importantly, IRS not only leads to minimal harm/damage from MAE, but also teaches employees to learn lessons from dealing with MAE. In this study, we take a regional hospital as a case and propose a four-stage methodology, namely, documentation, rationalization, standardization and information, for establishing an institutional internal reporting system for patient safety. In the case-hospital, the proposed IRS provides an effective feedback mechanism for MAE, and sends those events with their severity assessment code larger than two to the Root-Cause-Analysis team for further discussions. All the employees in the hospital may learn the experience in dealing with those MAE via the knowledge sharing web-pages in the IRS. Our study also observes that IRS helps in saving significant efforts for preparing documents and manual operations for taking care of patient safety problems. Furthermore, the convenience as well as the encouragement of no-penalty from the proposed IRS dramatically improves the employees’ motivation of reporting MAE and successfully builds an excellent organizational culture on patient safety.