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1 1,2,3,4,5,6 Institute of Medicine 1999 To Err is Human 7 44,000 98,000 WHO 2004 (World Alliance for Patient Safety) (8) / AE / AE (%) (%) US/ The Harvard Medical Practice 1984/NY 51/30, ( ) Study/ Brennan et al US/UTCOS/ 1992/Utah 2.9 ( 28/15, Thomas et al &Colorado ) Aus/QAHCS/ Wilson et al New Zealand/ Davis UK/ Vincent et al /14, / (High preventability) /1,

2 / AE / AE (%) (%) Canada/ 37 (Potential /3, Baker et al preventability) WHO 1/ World Health AssemblyWHA WHO (World Alliance for Patient Safety) (8) (Patient Safety Challenge): 2005/06 (Patients for Patient Safety) (Taxonomy for Patient Safety) (Research for Patient Safety) (Solutions for Patient Safety) (Reporting and Learning) (JCAHO) - 2 -

3 Robinson IOM 14% vs. 19% 29% vs. 67% 24% vs. 60% 54% vs. 90% Blendon % vs. 20% 89% 86% - 3 -

4 International Patient Safety Event Taxonomy (IPSET) 18 (adverse event) (near miss) (National Quality Forum)2003 (creating a culture of safety) (matching healthcare needs with service delivery capability) (facilitating information transfer and clear communication) (adopting safety practice in specific setting or process of care) (increasing safe medication use) NPSA (Seven Steps to Patient Safety: An overview guide for NHS staff) Build a safety culture Lead and support your staff Integrate your risk management activity Promote reporting - 4 -

5 Involve and communicate with patients and the public Learn and share safety lessons Implement solutions to prevent harm

6 WHO % 12% 10% 10% 9% 8.6% 6% 5.5% 5.5% 4% 3.4% 3% % (26.5%/ 21.2%) (11.9%/ 8.6%) (10.2%/ 8.3%) (10.1%/ 11.1%) (8.8%/ 8.6%) - 6 -

7 Root Cause Analysis; RCA - 7 -

8 13-8 -

9 (76%) 8.2% 3.4% 2.2% 17.8% (66.8%) (23.4%) (29.7%) (44%) NEJM (National Patient Safety Agency, NPSA) - 9 -

10 (National Reporting and Learning System, NRLS) (Be Opening) NPSA E-learning NPSA :

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14 RCA

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17 JCAHO

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19 Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery

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21 % % % % % % % % % % % % % Total 3254* % *

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24 ~ Total 71.8 % 28.2 % % 69.6 % ~ % 0 0.0% % 2 6.9% % 21.4 % % % 50.0 % % 47.0 % 2 6.9% 0 0.0% 8 3.0% 200~ % 0 0.0% 0 0.0% 2 6.9% 0 0.0% 2 0.8% 300~ % 0 0.0% 1 3.6% 0 0.0% 0 0.0% 1 0.4% 400~ % 0 0.0% 0 0.0% 2 6.9% 0 0.0% 2 0.8% % 0 0.0% 0 0.0% 0 0.0% 3 Total % % % % % % 3 1.5% % : ( )

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29 Q1 X KUB A1 medical error medical adverse event Q2 A X B error near miss? A2 medical error near miss Q3 2 1 A3 Q4 A4-29 -

30 Q5? A5 Q A6 Q&A

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34 Patient Safety Indicators (PSIs) PSIs Accidental puncture or laceration Complications of anesthesia Death in low-mortality diagnosis-related groups (DRGs) Decubitus ulcer Failure to rescue Foreign body left during procedure Iatrogenic pneumothorax Postoperative hemorrhage or hematoma Postoperative hip fracture Postoperative physiologic and metabolic derangement Postoperative pulmonary embolism (PE) or deep vein thrombosis (DVT) Postoperative respiratory failure Postoperative sepsis Postoperative wound dehiscence Selected infections due to medical care Transfusion reaction Birth trauma injury to neonate Obstetric trauma Cesarean delivery Obstetric trauma vaginal delivery with instrument Obstetric trauma vaginal delivery without instrument Accidental puncture or laceration Foreign body left during procedure Iatrogenic pneumothorax Selected infections due to medical care Postoperative wound dehiscence Transfusion reaction

35 D

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38 21 ISQuaBMJ 2003 SARS SARS SARS

39 Logo Delivery LOVE

40 DR.VAHE SARS SARS (JCQHC)

41 DR.VAHE

42 ( )

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47 RCA FMEA Root cause analysis (sentinel events) (root causes) (action plans) RCA RCA

48 RCA RCA JCAHO RCA 21 RCA (Partnership for Patient Safety, P4PS) (Risk Management Foundation of the Harvard Medical Institutions) First Do No Harm Methergin Vit K RCA RCA P4PS RCA RCA RCA (

49 ) RCA RCA 93 RCA ( )

50 (Health Quality Improvement CircleHQIC)

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53 JCAHO

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59 NPSA (National Reporting and Learning System, NRLS) (Be Opening) NPSA E-learning

60 1. Brennan TA etc. Incidence of adverse events and negligence in hospitalized patients. N Engl J Med ;6; Leape LL etc. The nature of adverse events in hospitalized patients. N Engl J Med ;6; Localio AR etc. Relation between malpractice claims and adverse events due to negligence. N Engl J Med ;4; Wilson RM, Runciman WB, Gibberd RW etc. The quality in Australian health care study Med J Aust ; Wilson RM, Harrison BT, Gibberd RW etc. An analysis of the causes of adverse events from the Quality in Australian Health Care Study Med J Aust ; Thomas EJ, Studdert DM, Burstin HR etc. Incidence and types of adverse events and negligent care in Utah and Colorado. Medical Care ;3; Kohn LT, Corrigan JM, Donaldson MS. (ed) 1999 To err is human: building a safer health system. National Academy Press: Washington, DC 8. World Health Organization (2004), World Alliance for Patient Safety: forward programme, World Health Organization: Geneva 9. Robinson AR, Hohmann KB etc. Physician and public opinions on quality of health care and the problem of medical errors. Arch Intern Med ; Blendon RJ, DesRoches CM etc. Views of practicing physicians and the public on medical errors. N Engl J Med ;24; (2003)

61 12. (2003) AHRQ Quality Indicators Guide to Patient Safety Indicators. Rockville, MD: Agency for Healthcare Research and Quality, 2003 AHRQ Pub.03-R Zhan, C. And Miller, M.R. (2003), Administrative Data Based Patient Safety Research: A critical review Qual Saf Health Care, 12(Suppl ii):ii58-ii (2004) 18. Institute for Safe Medication Practices (ISMP), 2001, Medication Safety Self Assessment for Community/Ambulatory Pharmacy 19. Smetzer, J.L., Vaida, A.J., Cohen, M.R., Tranum, D., Pittman, M.A. and Armstrong, C.W. (2003), Findings from the ISMP Medication Safety Self Assessment for Hospitals Joint Commission Journal on Quality and Safety, 29(11):p Sprenger, S.L. and Hanold, L.S. (2004), Building A Framework for Comprehensive Indicator Measurement, present in 21 th International Society for Quality in health Care, ISQua annual conference, (Abstract #238, Session B21)

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征求意见稿

征求意见稿卫办医政函 2011 54 号卫生部办公厅关于印发三级综合医院医疗质量管理与控制指标 (2011 年版 ) 的通知各省自治区直辖市卫生厅局, 新疆生产建设兵团卫生局 : 为建立完善适合我国国情的医疗质量管理与控制体系, 促进医疗质量管