醫療安全偵測之利器－－以病歷調查為工具

Measuring Healthcare Safety - Using Medical Record Review Method

意外事件通報強調自願性、無懲罰及匿名性。但由台灣病人安全通報系統發現醫院所通報的意外事件，嚴重度輕微或無傷害佔大多數；IHI報告中也發現，僅有10%~20%的錯誤會通報出來，其中有90%~95%是無傷害事件。因此，醫院需要有效的方法找出造成病人傷害的事件。採用IHI全面性觸發工具審查病歷偵測醫療不良事件：一、審查符合以下條件的病歷：出院超過30天、完成病歷書寫、住院超過1天及年齡18歲以上。二、每兩週隨機抽樣，完成10本病歷分析。三、組成意外事件病歷審查小組，依據NCCMERP之嚴重度等級和IHI全面性觸發工具調查病歷中之醫療不良事件，並進行審查一致性訓練。病歷審查成員間審核一致性評估由85%提升至95%。至2012年12月31日共計審查960本病歷，不良事件發生率平均為43.1%，嚴重度E:42%、F:45%、G:5%、H:0%、I:8%。不良事件發生率平均值由2009年的74.7‰逐年下降至46.1‰（2010年）、36.7‰（2011年）、24.2‰（2012年）。運用全面性觸發工具審查病歷，可以成功的偵測到未通報之醫療不良事件，並進行原因探討且追蹤系統改善，可有效降低不良事件發生率，提昇醫院安全。

In reporting incidental events we emphasize on three things, i.e. on a voluntary basis, no penalty to be involved, and to be anonymous. However, from what we've learned in the existing Taiwan Patient Safety Reporting System that the great majority of the events reported through the system were either of little harm or no harm at all. A recent report by the Institute of Healthcare Improvement (IHI) on this very topic also indicated that only 10%~20% of all errors that presumably did take place were reported, of which 90%~95% turned out to be quite harmless. Therefore, the hospital needs a much more effective way to find out events causing harm to the patients. In this study we adopted the IHI Global Trigger Tool to look into our patient health records to monitor the so-called adverse events. The process included: 1. picking out records meeting the following criteria: the patient has been released by the hospital more than 30 days, the health record has been completed in writing, the patient stayed at the hospital for more than one day, and the patient was 18 or older; 2. in every two weeks we selected in random 10 such health records and completed the analysis; and 3. organizing an Incident in Health Record Review Task force and utilized the NCC NERP Severity Scale and the IHI Global Trigger Tool to find out adverse events in those records. At the same time, training was conducted to standardize the review procedures to better consistency. During the study we found the consistency of the reviews made by our task force members was enhanced from 85% to 95%. From January 2009 to December 31, 2012, we reviewed a total of 960 medical records, and the finding showed the average rate of adverse events/1,000 patient-days was 43.1 and decreasing annually from 74.7 (2009), 46.1 (2010), 36.7 (2011) to 24.2 (2012). Categories of harm are E: 42%; F: 45%; G: 5%; H: 0%; I: 9%. In conclusion, we found using the IHI global trigger tool in our health record review did help us successfully detect adverse events that evaded in our old system. This allowed us to look into the causes to better our tracking system, and effectively lowered down the occurrence rate of adverse events and improve the safety of the hospital as well.