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 51/30,121 3.7( 13.6 58 ) Study/ Brennan et al US/UTCOS/ 1992/Utah 2.9 ( 28/15,000 6.6 53 Thomas et al &Colorado ) Aus/QAHCS/ Wilson et al New Zealand/ Davis UK/ Vincent et al 1992 28/14,179 16.6 51 1998 13/6579 11.3 37(High preventability) 1999-2000 2/1,014 12.9 48-1 -
/ AE / AE (%) (%) Canada/ 37 (Potential 2001 20/3,720 7.5 Baker et al preventability) WHO 1/10 2002 55 World Health AssemblyWHA WHO (World Alliance for Patient Safety) 2004 10 (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 -
Robinson 1000 500 9 IOM 14% vs. 19% 29% vs. 67% 24% vs. 60% 54% vs. 90% Blendon 2002 10 831 1207 49% vs. 20% 89% 86% - 3 -
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 -
Involve and communicate with patients and the public Learn and share safety lessons Implement solutions to prevent harm 11 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. - 5 -
WHO 93 12 23% 12% 10% 10% 9% 8.6% 6% 5.5% 5.5% 4% 3.4% 3% 93 38.9% 92 92 93 (26.5%/ 21.2%) (11.9%/ 8.6%) (10.2%/ 8.3%) (10.1%/ 11.1%) (8.8%/ 8.6%) - 6 -
93 5 92 Root Cause Analysis; RCA - 7 -
13-8 -
92 92 12 (76%) 8.2% 3.4% 2.2% 17.8% (66.8%) (23.4%) (29.7%) (44%) NEJM 2002 42 (National Patient Safety Agency, NPSA) - 9 -
(National Reporting and Learning System, NRLS) (Be Opening) NPSA E-learning NPSA : - 10 -
- 11 -
- 12 -
1 1. 2. - 13 -
3. 4. 5. RCA 2 1. 2. 3. 4. 1 2 3 1 2 3-14 -
- 15 -
- 16 -
JCAHO - 17 -
- 18 -
Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery - 19 -
- 20 -
570 17.52% 469 14.41% 364 11.19% 279 8.57% 279 8.57% 271 8.33% 181 5.56% 174 5.35% 157 4.82% 148 4.55% 135 4.15% 120 3.69% 107 3.29% Total 3254* 100.00% * - 21 -
- 22 -
- 23 -
10 102 10~100 40 100 100-300 300-500 500-1000 1000 Total 71.8 % 28.2 % 17 39 30.4 % 69.6 % 20 100~200 0 0.0% 0 0.0% 6 1 3.6% 2 6.9% 1 71.4 % 21.4 % 21 72.4 % 4 12.5 % 50.0 % 123 124 46.6 % 47.0 % 2 6.9% 0 0.0% 8 3.0% 200~300 0 0.0% 0 0.0% 0 0.0% 2 6.9% 0 0.0% 2 0.8% 300~400 0 0.0% 0 0.0% 1 3.6% 0 0.0% 0 0.0% 1 0.4% 400~500 0 0.0% 0 0.0% 0 0.0% 2 6.9% 0 0.0% 2 0.8% 500 0 0.0% 0 0.0% 0 0.0% 0 0.0% 3 Total 142 100.0 % 56 100.0 % 28 100.0 % 29 100.0 % 8 37.5 % 100.0 % 3 1.5% 100.0 263 % : ( ) - 24 -
- 25 -
- 26 -
- 27 -
- 28 -
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 -
Q5? A5 Q6 93 4 A6 Q&A - 30 -
- 31 -
- 32 -
- 33 -
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 - 34 -
D - 35 -
- 36 -
- 37 -
21 ISQuaBMJ 2003 SARS SARS SARS 92 4 1718 600-38 -
Logo Delivery LOVE - 39 -
DR.VAHE SARS SARS (JCQHC) - 40 -
DR.VAHE 1. - 41 -
2. 3. 4. 5. 6. 7. 93 1 5 2 20 203 35 80 56 12 25 12 6 2 3 ( ) 12 35-42 -
23 54 3 80 11 17 35 19 11 31 2 2 2 2 3 5 5 2 4 35-43 -
- 44 -
120-45 -
7-8 253 74 507-46 -
73 87 1. 2. 3. RCA FMEA 4. 5. Root cause analysis (sentinel events) (root causes) (action plans) RCA RCA - 47 -
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 ( - 48 -
) RCA RCA 93 RCA ( ) 2000 1 2 1 1 5 1 1 1 1 2 1 1 3 1 5 1 4 13 5 1 5-49 -
(Health Quality Improvement CircleHQIC) 150 65 15-50 -
- 51 -
8000-52 -
JCAHO - 53 -
- 54 -
- 55 -
1. - 56 -
2. 3. 4. 5. 6. - 57 -
- 58 -
NPSA (National Reporting and Learning System, NRLS) (Be Opening) NPSA E-learning - 59 -
1. Brennan TA etc. Incidence of adverse events and negligence in hospitalized patients. N Engl J Med 1991 324;6;370-376 2. Leape LL etc. The nature of adverse events in hospitalized patients. N Engl J Med 1991 324;6;377-384 3. Localio AR etc. Relation between malpractice claims and adverse events due to negligence. N Engl J Med 1991 325;4;245-251 4. Wilson RM, Runciman WB, Gibberd RW etc. The quality in Australian health care study Med J Aust 1995 163;458-471 5. 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 1999 170;411-415 6. Thomas EJ, Studdert DM, Burstin HR etc. Incidence and types of adverse events and negligent care in Utah and Colorado. Medical Care 2000 38;3;261-271 7. 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 2002 162;2186-2190. 10. Blendon RJ, DesRoches CM etc. Views of practicing physicians and the public on medical errors. N Engl J Med 2002 347;24;1933-40. 11. (2003) - 60 -
12. (2003) 13. 14. http://www.jcaho.org/accredited+organizations/patient+safety/npsg.htm 15. AHRQ Quality Indicators Guide to Patient Safety Indicators. Rockville, MD: Agency for Healthcare Research and Quality, 2003 AHRQ Pub.03-R203 16. Zhan, C. And Miller, M.R. (2003), Administrative Data Based Patient Safety Research: A critical review Qual Saf Health Care, 12(Suppl ii):ii58-ii63 17. (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):p586-597 20. 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) - 61 -
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