INCIDENT REPORTING IN NURSING HOMES

描述（由申请人提供）：每年，大约有800万起不良事件发生在脆弱的养老院（NH）居民中。不良事件定义为“非计划事件 对患者造成或有可能造成伤害。“在NH环境中发生的各种不良事件包括福尔斯;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。根据其严重程度，这些事件的发生可能会导致严重的发病率和死亡率，并随后导致相当多的NH工作人员的时间和成本增加，以照顾他们。" 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领域，大大加强了安全举措。调查不良事件周围的情况对于改善预防和干预工作非常重要，使用事件报告系统旨在通过数据分析改善医疗保健流程。这一过程需要对事件、数据元素以及收集和整合数据的方法进行标准化定义。 进一步的研究是必要的，目前的做法，如何在疗养院事件进行评估。此外，为了改善事件的报告和分析质量改进，卫生信息技术（HIT）在这奋进发挥的作用，应进行调查。本研究的目的是检查事件报告的做法在NHs，并确定在何种程度上这些数据用于提高居民的安全。最终，这项研究预计将增加知识基础，这将有助于研究人员改善不良事件评估的工作流程设计和HIT和医疗保健政策的发展在这方面发挥的作用。这些信息将促进我们制定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.