不良事件上报制度的理论基础与临床实践  

The principle and practice of adverse events reporting system

作　　者：赵金宪[1] 朱斌[2] ZHAO Jinxian;ZHU Bin(Department of Endocrinology,Affiliated Fuxing Hospital,Capital Medical University,Beijing 100038;Department of Anesthesiology,Peking University International Hospital,Beijing 102206,China)

机构地区：[1]首都医科大学附属复兴医院内分泌科,北京100038 [2]北京大学国际医院麻醉科,北京102206

出　　处：《麻醉安全与质控》2018年第2期66-69,共4页Perioperative Safety and Quality Assurance

摘　　要：从质控管理和患者安全角度,任何运转的医疗体系都存在"系统缺陷"和"人为错误"的可能。加强医疗系统安全建设,应建立、执行并规范不良事件和安全隐患上报制度,从制度层面去纠正系统缺陷,减少人为犯错误几率,来预防可以预防的错误,避免可以避免的问题,从而最终获得医疗系统安全的持续改进。Based on Heinrich's and Murphy's law,any medical system has system defects and human errors.In order to improve perioperative safety,adverse and near miss events reporting system should be established,implemented and standardized.This will facilitate the remedy of system defects and reduction of human errors,help to eliminate preventable mistakes and adverse events,and eventually improve medical quality.

关 键 词：医疗安全 不良事件 上报制度 

分 类 号：R197.3[医药卫生—卫生事业管理]