上海交通大学学报(医学版)

• 论著(公共卫生) • 上一篇    下一篇

基于医院信息化的医疗不良事件内部报告系统构建

杨静1,2,张静1,张智若1,郑志杰1   

  1. 上海交通大学 1.公共卫生学院, 2.医学院附属瑞金医院, 上海 200025
  • 出版日期:2016-03-28 发布日期:2017-06-02
  • 通讯作者: 张智若, 电子信箱: zhangzhiruo@sjtu.edu.cn; 郑志杰, 电子信箱: zheng22762@live.com。
  • 作者简介:杨静(1984—), 女, 硕士生; 电子信箱: rjhospitalyj@163.com。

Establishment of an internal reporting system of medical adverse events based on hospital informatization

YANG Jing1,2, ZHANG Jing1, ZHANG Zhi-ruo1, ZHENG Zhi-jie1   

  1. 1.School of Public Health, 2.Ruijin Hospital,Shanghai Jiao Tong University, Shanghai 200025, China
  • Online:2016-03-28 Published:2017-06-02

摘要:

目的 探索构建基于住院信息系统及协同办公系统的医疗不良事件内部网络报告体系,统一分类标准,规范上报术语,以期提高不良事件的报告效率,优化医疗安全管理。方法 在检索国内外医疗不良事件报告系统相关文献的基础上,结合前期定性定量研究结果,设计并构建基于医院信息化的医疗不良事件内部报告系统。结果 构建由事件上报、事件查询、统计分析、权限管理和系统设置五大功能模块组成的医疗不良事件内部报告系统,该系统可以嵌入电子病历系统中,在协同办公系统中实现流转。在技术关键上实现了分期报告、准确分类,上报要素分类遴选,统一规范的预设项设置等,兼顾了临床的可操作性和数据提取的规范、完整性。结论 上报系统的应用可提高不良事件的上报效率,从而在一定程度上提高临床医师的上报意愿。系统采集的信息便于职能部门后期进行数据统计及类比分析,总结发生不良事件的规律性问题,查找系统风险,制定改进措施,提高医疗安全管理的效率。

关键词: 医疗不良事件, 内部报告系统, 医院信息化

Abstract:

Objective To explore the establishment of internal network reporting system of medical adverse events based on the hospitalization information system and cooperative office system, unify the classification criteria, and normalize reporting terms in order to improve the reporting efficiency for adverse events and optimize medical safety management. Methods Combined with previous qualitative and quantitative research results, the internal reporting system of medical adverse events was designed and established based on the hospital information system according to retrieved literature on reporting system of medical adverse events both at home and abroad. Results The internal reporting system of medical adverse events, which consisted of five functional modules, namely event reporting, events inquiry, statistics and analysis, authority management and system setting, was established. The reporting system can be embedded in the electronic medical record system and circulate in the cooperative office system. Realized key technologies included staging reporting, precise classification, classification and screening of reporting factors, and unified and normalized default settings. The system also took into account the clinical operability, as well as standardization and integrity of data collection. Conclusion The application of the reporting system can increase the reporting efficiency for adverse events, thus improving the reporting willingness of clinicians to a certain extent. The information collected by the system is convenient for functional departments to perform data statistics and analogy analysis, summarize regular problems in adverse events, identify system risks, and develop improving measures, so as to elevate the efficiency of medical safety administration.

Key words: medical adverse events, internal reporting system, hospital informatization