A national incident reporting and learning system in England and Wales, but at what cost?

Carter, Alexander W; Mossialos, Elías; Darzi, Ara

doi:10.1586/14737167.2015.1031114

Cited by 5 publications

(3 citation statements)

References 12 publications

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“…A jelentések szakmai tartalma is jelentősen eltér egymástól, bár többnyire szabad szöveges leírásokat várnak a rendszerek [6]. Az mindenképpen közös a nemzetközi programokban, hogy a beérkezett jelentések feldolgozása időigényes és jelentős humán erőforrás és költség igénye van [14]. A magyar rendszer különleges abból a szempontból, hogy csak megadott témakörökben lehet jelentést küldeni, és olyan előre kidolgozott adatlapokat töltenek ki az intézmények, amelyek segítségével az esetekhez vezető leggyakoribb történések, okok, körülmények statisztikailag elemezhetők emberi erőforrás igénye nélkül is.…”

Section: Megbeszélésunclassified

A hibákból és a nemkívánatos eseményekből való tanulás – módszertani áttekintés a témaspecifikus tanulmányokhoz

Belicza

Adamik

2021

IME

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Az egészségügyi ellátások során kialakuló nem várt események adatainak gyűjtését szolgálja a WHO és az Egészségügyi Minisztérium kezdeményezésére létrehozott NEVES jelentési rendszer. Az ide beérkezett, megtörtént események részletes adatait tartalmazó jelentéseket hét témakörben dolgoztuk fel az általunk kidolgozott, aggregált jelentési adatokra támaszkodó módszertani útmutató alapján. A dolgozat ismerteti ezen módszertan legfontosabb lépéseit és eszköztárát. Ez segíti az intézmények saját adataikra támaszkodó tanulását, a betegbiztonsági intézkedések megfogalmazását és végrehajtását, valamint bevezetőként szolgál a tanulmányok bemutatását célzó cikksorozathoz.

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Section: Megbeszélésunclassified

A hibákból és a nemkívánatos eseményekből való tanulás – módszertani áttekintés a témaspecifikus tanulmányokhoz

Belicza

Adamik

2021

IME

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“…No entanto, a notificação tanto de eventos adversos como incidentes near miss, entendidos como quase erro devido à detecção da falha antes de atingir o paciente, não é foco de atenção dos gestores e, ainda, pouco se valoriza este tipo de notificação (2) . Sabe-se que possuem procedência semelhante sendo necessá-ria a análise de sua causa raiz, para que medidas preventivas sejam instauradas antes que atinjam os pacientes (3)(4)(5) .…”

Section: Resumen |unclassified

Near miss na atenção primária í saúde e a segurança do paciente

Amaro

Schveitzer

Bohomol

2021

Nursing (São Paulo)

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Objetivo: Identificar as evidências sobre os incidentes near miss em serviços de atenção primária à saúde. Método: Revisão integrativa de literatura a partir de artigos primários publicados em sete bases de dados. Utilizou-se os descritores “near miss”, “atenção primária à saúde” e “gestão da segurança” sem limitações quanto ao ano de publicação e idiomas. Resultados: Os tipos de incidentes near miss notificados com maior frequência estavam relacionados a erros de medicação, com variação entre 6,2% e 96%, e o processo de prescrição foi o mais recorrente. Os profissionais de saúde foram os responsáveis por interceptar entre 66% a 83% dos incidentes. Conclusão: A notificação de incidentes near miss deve ser incentivada e incorporada nas práticas gerenciais. Conhecer precocemente os erros e seu potencial de dano possibilita ações de melhorias para segurança do paciente.

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“…Extensive and carefully planned specialized information platforms for surgical sectors are, therefore, needed to collect data on patient safety [7]. Several nationwide surgical complication reporting and learning systems have, therefore, been developed in the past two decades, such as the United Kingdom’s National Reporting and Learning System [8]. This was established in late 2003 as a voluntary scheme for reporting patient safety incidents, to support learning from these incidents.…”

Section: Introductionmentioning

confidence: 99%

Key Issues in the Development of an Evidence-Based Stratified Surgical Patient Safety Improvement Information System: Experience From a Multicenter Surgical Safety Program

Han

Jiang

et al. 2019

J Med Internet Res

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Surgery is still far from being completely safe and reliable. Surgical safety has, therefore, been the focus of considerable attention over the last few decades, and there are a growing number of national drives to improve it. There are also a number of large surgical complication reporting systems and system-based interventions, both of which have made remarkable progress in the past two decades. These systems, however, have either mainly focused on reporting complications and played a limited role in guiding practice or have provided nonselective interventions to all patients, perhaps imposing unnecessary burdens on frontline medical staff. We have, therefore, developed an evidence-based stratified surgical safety information system based on a multicenter surgical safety improvement program. This study discusses some critical issues in the process of developing this information system, including (1) decisions about data gathering, (2) establishing and sharing knowledge, (3) developing functions for the system, (4) system implementation, and (5) evaluation and continuous improvement. Using examples drawn from the surgical safety improvement program, we have shown how this type of system can be fitted into day-to-day clinical practice and how it can guide medical practice by incorporating inherent patient-related risk and providing tailored interventions for patients with different levels of risk. We concluded that multidisciplinary collaboration, involving experts in health care (including senior staff in surgery, nursing, and anesthesia), data science, health care management, and health information technology, can help build an evidence-based stratified surgical patient safety improvement system. This can provide an information-intensified surgical safety learning platform and, therefore, benefit surgical patients by delivering tailored interventions and an integrated workflow.

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A national incident reporting and learning system in England and Wales, but at what cost?

Cited by 5 publications

References 12 publications

A hibákból és a nemkívánatos eseményekből való tanulás – módszertani áttekintés a témaspecifikus tanulmányokhoz

A hibákból és a nemkívánatos eseményekből való tanulás – módszertani áttekintés a témaspecifikus tanulmányokhoz

Near miss na atenção primária í saúde e a segurança do paciente

Key Issues in the Development of an Evidence-Based Stratified Surgical Patient Safety Improvement Information System: Experience From a Multicenter Surgical Safety Program

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