Learning from Taiwan patient-safety reporting system

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Abstract

Objective

The aim of this study is to create a national database to record incidents that endanger patient safety. We try to identify systemic problems in hospitals in order to avoid safety incidents in the future and improve the quality of healthcare.

Method

The Taiwan Patient Safety Reporting System employs a voluntary notification model. We define 13 types of patient safety incidents, and the reports of different types of incidents are recorded using common terminology. Statistical analysis is used to identify the incident type, time of occurrence, location, person who reported the incident, and possible reasons for frequently occurring incidents.

Results

There were 340 hospitals that joined this program from 2005 to 2010. Over 128,271 incident events were reported and analyzed. The three most common incidents were drug-related incidents, falls, and endo tube related incidents. By analyzing the time of occurrence of incidents, we found that drug-related incidents usually occurred between 8 and 10 am. Falls and endo tube incidents usually occurred between 4 and 6 am. The most common location was wards (57.6%), followed by intensive care areas (13.5%), and pharmacies (9.1%). Among hospital staff, nurses reported the highest number of incidents (68.9%), followed by pharmacists (14.5%) and administrative staff (5.5%). The number of incidents reported by doctors was much lower (1.2%). Most staff members who reported incidents had been working for less than five years (58.1%).

Conclusion

The unified reporting system was found to improve the recording and analysis of patient safety incidents. To encourage hospital staff to report incidents, hospitals need to be assisted in establishing an internal report and management system for safety incidents. Hospitals also need a protection mechanism to allow staff members to report incidents without the fear of punishment. By identifying the root causes of safety incidents and sharing the lessons learned across hospitals is the only way such incidents can be stopped from happening again.

Highlights

► The Patient-safety Reporting System must consist of internal hospital reporting systems and national reporting systems. ► The three most common incidents were drug-related incidents, falls, and endo tube related incidents. ► The implementation of safety promotion and improvement plans can help to better guarantee patient safety. ► Hospitals need a protection mechanism to allow staff members to report incidents without the fear of punishment.

Introduction

Patient safety risks and incidents of negligence are widely reported in the media, and have induced considerable debate in academic and medical circles [1], [2], [3], [4]. The Institute of Medicine, an American think tank, described in its 1999 report “To Err is Human” that approximately 44,000–98,000 persons die from medical negligence every year in the US [5]. Vincent et al. [6] made the preliminary discovery that close to 11% of patients suffered adverse events while hospitalized. It is clear that fostering a notification culture among medical, nursing, ancillary and administrative personnel, and establishing patient safety reporting platforms, can help reduce medical errors and adverse or near-miss events, and by doing so, improve hospital care quality [7], [8], [9].

Notification of medical incidents may be either voluntary or compulsory [10]. Voluntary notifications are most often connected with sharing knowledge; compulsory notifications are usually used to report major medical incidents [11]. Because most users of hospital patient safety notification systems are nursing personnel [12], the adoption of information technologies can help them to manage and analyze medical incidents. For example, use of Web technology can facilitate user input [13] and analyze adverse events [14]. Benjamin Honigman and Harvey J. Murff found that computer analysis of case history texts could greatly assist discovery of incidents [15], [16].

This study explains the deployment of the Taiwan Patient-Safety Reporting (TPR) System via the three aspects of (1) planning notification operating procedures, (2) designing form content, and (3) reporting the platform development model. It also analyze data retrieved from the national database, and describes interventions as a result of data analysis.

Section snippets

National patient safety reporting policy

It is not individuals but the whole system that is responsible for patient safety. Therefore, the TPR system protects the privacy of the staff and patients involved in such incident by not storing any identifying information about them. The only thing we are concerned with is identifying the causes of the incidents, and preventing similar incidents from happening in the future. The TPR system employs a voluntary notification model. Everyone in the hospital can report patient safety incidents

Results

When the first stage of this project was conducted in 2005, we completed the national patient safety reporting system, and provided the web-based interface to medical organizations nationwide for use in reporting incidents online. Only 26 hospitals that had not established internal reporting systems participated in the project and approximately 400 incidents were uploaded throughout this period. The reason for this rather unsatisfactory reporting situation was that the medical organizations

The development strategy of patient safety reporting system

Before establishing a national patient safety information sharing platform, we had to first set up a unified reporting framework. It is essential to establish a set of incident taxonomy (for example, how the seriousness of an incident is ranked and how incidents are categorized) that can be widely accepted by all participating organizations. With a common taxonomy, each medical institution can report incidents on a shared platform and analyze the data to produce meaningful information.

Because

Conclusion

The emphasis on patient safety and measures for continuous improvement are important for improving the quality of medical care. The purpose of incident reporting system is to identify the systemic problems in hospitals. Therefore, changing the management culture in hospitals and addressing the concerns of staff members about being punished for reporting incidents are the first steps needed to establish an effective reporting system. Most hospitals want to have a patient management system.

Conflict of interest

None.

Author contributions

Chung-Chih Lin designed the study, system implementation, data collection, organized the analysis, and drafted the manuscript. Chung-Liang Shih designed the study and revised the final manuscript. Hsun-Hsiang Liao data collection and conducted the work site survey. Cathy HY Wung provided topic expertise.

Summary points

What was known before the study?

  • Patient safety risks and incidents of negligence have induced considerable debate in academic and medical circles.

  • It is clear that establishing

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