CAJ | 학술논문

目的：建立科学的医疗不良事件报告系统并使之有效运行。方法借鉴SH9医疗不良事件分级法，建立符合医院实际情况的标准化工作流程，以鼓励主动报告为手段提升上报率。结果2014年度共上报医疗不良事件289例，其中近半数为隐患事件，事件归因多集中在患者服务流程及护理服务质量方面，事件处理两周内整改完成率为86．45％，事件教训分享53例。结论统一的事件分级加归因分类、方便快捷的网报途径、自觉自愿的责任意识驱动上报、及时切实地解决问题是保障医疗不良事件报告系统有效运行的关键所在。
목적：건립과학적의료불량사건보고계통병사지유효운행。방법차감SH9의료불량사건분급법，건립부합의원실제정황적표준화공작류정，이고려주동보고위수단제승상보솔。결과2014년도공상보의료불량사건289례，기중근반수위은환사건，사건귀인다집중재환자복무류정급호리복무질량방면，사건처리량주내정개완성솔위86．45％，사건교훈분향53례。결론통일적사건분급가귀인분류、방편쾌첩적망보도경、자각자원적책임의식구동상보、급시절실지해결문제시보장의료불량사건보고계통유효운행적관건소재。
Objective To establish a medical adverse event reporting system and make it run efficiently. Methods Based on SH9 medical adverse events classification, the reporting system and standardized work protocol were established to process medical adverse event.Results 289 medical adverse events were reported, nearly half of the events were near-miss events.The events are mostly concentrated in the patient care process and services. 86.45%of the improvement measures were executed within two weeks, and experience of 53 events were shared. Conclusion The standards of events classification, convenient way of network reported, the sense of responsibility and timely event solve were the keys of medical adverse event reporting system.