醫院內部醫療異常事件通報管理資訊系統建置與導入之個案研究－－以某區域教學醫院為例

Development and Implement of Internal Medical Incident Event Reporting Management Information System: A Case Study of Regional Teaching Hospital

2002年北城婦幼醫院護理人員打錯針事件，造成幼兒一死六傷的慘劇，此事件促使相關主管機關與社會大眾開始重視病人安全問題。為此，衛生署特於2003年二月成立病人安全委員會，致力推動各項促進病患安全之教育訓練及活動，且積極規劃全國性的病人安全通報系統，以避免相同事件再次發生。此全國性的病人安全通報系統之基礎即為醫院內部異常事件通報管理資訊系統。唯有每個醫院均瞭解並使用院內醫療通報系統，才能落實全國性病人安全之管理。通報系統是一個讓人描述在何種情況下會導致醫療錯誤發生的重要工具。其目的為透過資訊的分享，讓大家可從經驗中學習，良好的內部通報系統可確保所有相關人員對主要傷害的熟悉，「異常事件通報」此一制度建構的良寙，則是建立更完善病人安全醫療體系之關鍵。根據薛亞聖研究結果顯示，台灣多數醫院（約70％）仍未利用資訊科技建置病人安全事件通報系統。因此，為使病人安全通報制度發揮其最大功效，本研究將建置一套供醫院內部所使用之醫療異常事件通報管理資訊系統，以建構更完善、安全的就醫環境，提升醫療品質。本研究利用系統開發之雛形法來建置本系統，並將此系統實際導入個案醫院。目前系統已經上線並實際運作，經評估後發現使用者的滿意度高於傳統紙本通報方式，整體而言，網路通報改善了原本紙本通報的缺點，如機密性不足、匿名性低、傳遞之簡便性、安全性及環保性低，而此通報系統所帶來之最大效益，則依序為節省人工傳遞時間、匿名性及機密性的提升。這些效益對提升通報意願之是有其正向之助益。本系統之建置及導入過程與系統雛型架構，將可作為未來醫療院所在建置醫療異常事件通報管理系統時之重要參考與依據。

After a nursing staff of North Town Woman & Children's Hospital made an error injection in 2002, the relevant government department pays more attention to patient safety. The Department of Health (DOH) established Patient Safety Committee in February, 2003 to promote several patients' security activities and education training, and the committee is actively planning nationwide reporting system at present. Reporting System is an important tool that helps to describe certain circumstances leading to medical error (Chiang, 2001). Through reporting system, people can share information and learn from experience. And a good internal medical adverse reporting system can ensure relevant personnel's familiarity to some main injuring. According to Shiue's study (2004), most hospitals (about 70%) have not utilized information science and technology to construct a patient safety reporting system. Therefore, in order to make greatest efficiency on patient safety system, this research constructs a patient safety reporting system for using inside the hospital to improve patient safety and enhance medical quality. The result of this study points out the factors why the personnel are not willing to use the medical adverse reporting system. These factors are as followed. First, the personnel think the reporting has only little effect on improving the medical quality. Second, the staff is lack of reporting knowledge. Third, the staff doesn't realize the advantage after reporting. Fourth, the personnel wonder who should report medical error. Finally, through the reporting, it's possible to break the rapport within colleagues. For this system built by our institute, the ease of use is the main factor affecting the user to apply the system. And the user have higher satisfaction rate on this systematic report than the traditional paper reporting system. The first three benefits include saving the time spent on transmitting artificially, reducing the making of reporting form, and enhancing the transmitting efficiency. And, comparing to paper reporting system, this systematic report have advantages such as saving the time spent on transmitting artificially, protecting the environment, and keeping secret effectively. These benefits mentioned above enhance the desire to use this systematic report. The development procedure and prototyping of this system can be the reference for medical institutes to construct their patient safety reporting system.