INCIDENT REPORTING IN NURSING HOMES

描述(由申请人提供)：每年大约有800万例不良事件发生在脆弱的疗养院(NH)居民中。不良事件定义为“计划外事件” 在医院环境中发生的各种不良事件，包括跌倒、药物不良事件或用药错误、居民争吵或其他类型的虐待，以及非跌倒相关的伤害，如烧伤、皮肤撕裂或瘀伤。根据其严重性，这些事件的发生可能会导致显著的发病率和死亡率，随后导致医院工作人员相当长的时间和更多的护理成本。 显然，这些事件代表了NHS的一个重大问题。减少不良事件的一个开始是使用报告系统。医学研究所的报告呼吁加强不良事件报告。报告做法的改进意义重大，因为事故报告系统已成功地用于航空安全等其他方面，以显着加强安全举措。调查不良事件周围的情况对于改进预防和干预工作很重要，使用事件报告系统的目的是通过分析数据来改进保健程序。这一过程需要对事件、数据元素以及收集和集成数据的方法进行标准化定义。 有必要对疗养院目前如何评估事件的做法进行进一步研究。此外，为了改进报告和分析事件的方式以提高质量，应该调查卫生信息技术(HIT)在这一努力中所起的作用。这项研究的目的是检查NHS的事件报告做法，并确定这些数据在多大程度上被用于改善居民的安全。最终，这项研究有望增加知识库，帮助研究人员改进不良事件评估的工作流程设计，以及HIT和医疗保健政策制定在其中所起的作用。这些信息将促进我们制定由医学研究所和其他机构建议的标准化事件报告机制。

DESCRIPTION (Provided by Applicant): Each year, approximately 8 million adverse incidents occur among vulnerable nursing home (NH) residents. An adverse incident is defined as "unplanned events which caused, or had the potential to cause, harm to patients." There are a variety of adverse incidents that occur in the NH setting including falls; adverse drug events or medication errors; resident altercations or other types of abuse; and non-fall related injuries such as burns, skin tears, or bruises. Depending on their severity, the occurrence of these incidents can lead to significant morbidity and mortality and subsequently result in considerable NH staff time and increased costs to care for them." Clearly, these incidents represent a significant problem in NHs. One start to reducing adverse incidents is to use reporting systems. The Institute of Medicine Reports call for enhancements in adverse incident reporting. Improvements in reporting practices is significant because incident reporting systems have been used successfully in other disciples such as aviation safety to significantly augment safety initiatives. Investigating the circumstances surrounding an adverse incident is important to improve prevention and intervention efforts and use of incident reporting systems is aimed at improving health care processes through the analysis of data. This process requires standardized definitions of the incident, data elements, and approaches for collecting and integrating the data. Further research is necessary on the current practice of how incidents are evaluated in nursing homes. Moreover, in order to improve how incidents are reported and analyzed for quality improvement, the role Health Information Technology (HIT) plays in this endeavor should be investigated. The purpose of this study is to examine the incident reporting practices in NHs and identify to what extent these data are used for improving the safety of residents. Ultimately, this research is expected to increase the knowledge base that will assist researchers to improve the workflow design of adverse incident evaluation and the role HIT and health care policy development plays in this. This information will further our development of a standardized incident reporting mechanism recommended by the Institute of Medicine and others.