International Comparative Analyses of Incidents Reporting Systems for Healthcare Risk Management△_Chinese Journal of Evidence-Based Medicine

Authors：

CUI Xiaohua ¹ , SUN Niuyun ² ,  LI Youping ¹ , ZHANG Zongjiu ³ , WANG Li ¹ , ZHOU Jun ³ , LIANG Minghui ² , CHENG Lan ¹ , GAO Guangming ³ , YUAN Qiang ¹

1. Chinese Evidence-based Medicine Center, West China Hospital, Sichuan University, Chengdu 610041, China;2. National Institute of Hospital Administration, Beijing 100083, China;3. Department of Medical Regulation, Ministry of Health, Beijing 100044, China;

Corresponding author：

LI Youping, Email: yzmylab@hotmail.com

Keywords：

Healthcare risk; Warning and monitoring; Management mode; Comparative analysis

DOI：

10.7507/1672-2531.20110040

Video：

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Objective 　To compare administration of incidence reporting systems for healthcare risk management in the United Kingdom, the United States, Canada, Australia, and Taiwan, and to provide evidence and recommendations for healthcare risk management policy in China.
Methods 　We searched the official websites of the healthcare risk management agencies of the four countries and one district for laws, regulatory documents, research reports, reviews, and evaluation forms concerned with healthcare risk management and assessment. Descriptive comparative analysis was performed on relevant documents.
Results 　(1) A total of 142 documents were included in this study. The United States had the most relevant documents (68). (2) The type of incidents from reporting systems has expanded from medication errors and hospital-acquired infections to near-misses, and now includes all patient safety incidents. (3) The incidence-reporting systems can be grouped into two models: government-led and legal/regulatory/NGO-collaborative. (4) In two cases, reporting systems were established for specific incident types: One for death or serious injury events (the sentinel events database in Britain, SIRL), and one for healthcare-associated infections (NHSN in America). (5) Compared to the four countries, Taiwan’s system put more emphasis on public welfare, confidentiality, and information sharing. The contents of reporting there covered every aspect of risk management to create a more secure environment.
Conclusion 　(1) Britain’s national reporting and learning system was representative of a government-led model; (2) The United States was the earliest country to have a reporting system, which included a limited range of incident types. Management of incidents became more reliable with increased application of laws, regulations, and guidances; (3) Both the Canadian and the Australian systems drew from the American experience and are still developing; (4) The Taiwanese system was comprehensive and is an instructional case.

Citation： CUI Xiaohua,SUN Niuyun,LI Youping,ZHANG Zongjiu,WANG Li,ZHOU Jun,LIANG Minghui,CHENG Lan,GAO Guangming,YUAN Qiang. International Comparative Analyses of Incidents Reporting Systems for Healthcare Risk Management△. Chinese Journal of Evidence-Based Medicine, 2011, 11(3): 237-246. doi: 10.7507/1672-2531.20110040 Copy

1.	1 Sun NY, Wang L, Zhou J, et al . International comparative analyses of healthcare risk management. Journal of Evidence-Based Medcine , 2011, 4(1):.
2.	ISMP Medication Errors Reporting Program (MERP). [2010-8-6] Available from: URL:https://www.ismp.org/orderforms/reporterrortoismp.asp.
3.	The Joint Commission.Sentinel Event Policy.[2010-8-2] Available from: URL:http://www.jointcommission.org/NR/rdonlyres/F84F9DC6-A5DA-490F-A91F-A9FCE26347C4/0/SE_chapter_july07.pdf.
4.	The Joint Commission. Alternatives for Sharing Sentinel Event-Related Information with The Joint Commission. [ 2010-8-2] Available from: URL:http://www.jointcommission.org/SentinelEvents/ReportingAlternatives/.
5.	USP. MEDMARX. [2010-8-2] Available from: URL: http://www.usp.org/hqi/patientSafety/medmarx/.
6.	Quantros Safety & Risk Management review. 2010-8-2http://www.quantros.com/pdf/Quantros_SRM_Overview-2010.pdf.
7.	The Journal’s Editorial Staff. A National Survey of Medical Error Reporting Laws. Yale Journal Of Health Policy, Law, And Ethics. IX:1 (2008) Available from: URL: http://www.yale.edu/yjhple/volume9issue1/p201-286_Feature%20TO%20PRINT.pdf.
8.	CDC.National Healthcare Safety Network (NHSN) Overview. [2010-8-10] Available from: URL:http://www.cdc.gov/nhsn/PDFs/pscManual/1PSC_OverviewCurrent.pdf.
9.	NPSA. Seven steps to patient safety.[2010-8-6] Available from: URL:http://www.nrls.npsa.nhs.uk/resources/collections/seven-steps-to-patient-safety/?entryid45=59787.
10.	NPSA Five actions to improve patient safety reporting.[2010-8-6] Available from: URL:http://www.nrls.npsa.nhs.uk/resources/?entryid45=59903.
11.	NPSA. National Framework for Reporting and Learning from Serious Incidents Requiring Investigation.[2010-8-16] Available from: URL: http://www.nrls.npsa.nhs.uk/resources/?entryid45=75173.
12.	CIHI. The Development of a Canadian Medication Incident Reporting and Prevention System (CMIRPS) for Canada.[2010-10-4] Available from: URL: http://www.hc-sc.gc.ca.
13.	Institute for Safe Medication Practices Canada (ISMP). Canadian Medication Incident Reporting and Prevention System. [2010-10-4] Available from: URL: www.ismp-canada.org.
14.	NPSF. Advanced Incident Management System (AIMS).[2010-8-23] Available from: URL:http://www.apsf.net.au/products.php.
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16.	台湾行政院卫生署. 台湾病人安全通报系统病人安全通报单（第五版）. [2010-11-2] Available from: URL: http://www.tpr.org.tw/dl/TPR_5(13)C.pdf.
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1. 1 Sun NY, Wang L, Zhou J, et al . International comparative analyses of healthcare risk management. Journal of Evidence-Based Medcine , 2011, 4(1):.
2. ISMP Medication Errors Reporting Program (MERP). [2010-8-6] Available from: URL:https://www.ismp.org/orderforms/reporterrortoismp.asp.
3. The Joint Commission.Sentinel Event Policy.[2010-8-2] Available from: URL:http://www.jointcommission.org/NR/rdonlyres/F84F9DC6-A5DA-490F-A91F-A9FCE26347C4/0/SE_chapter_july07.pdf.
4. The Joint Commission. Alternatives for Sharing Sentinel Event-Related Information with The Joint Commission. [ 2010-8-2] Available from: URL:http://www.jointcommission.org/SentinelEvents/ReportingAlternatives/.
5. USP. MEDMARX. [2010-8-2] Available from: URL: http://www.usp.org/hqi/patientSafety/medmarx/.
6. Quantros Safety & Risk Management review. 2010-8-2http://www.quantros.com/pdf/Quantros_SRM_Overview-2010.pdf.
7. The Journal’s Editorial Staff. A National Survey of Medical Error Reporting Laws. Yale Journal Of Health Policy, Law, And Ethics. IX:1 (2008) Available from: URL: http://www.yale.edu/yjhple/volume9issue1/p201-286_Feature%20TO%20PRINT.pdf.
8. CDC.National Healthcare Safety Network (NHSN) Overview. [2010-8-10] Available from: URL:http://www.cdc.gov/nhsn/PDFs/pscManual/1PSC_OverviewCurrent.pdf.
9. NPSA. Seven steps to patient safety.[2010-8-6] Available from: URL:http://www.nrls.npsa.nhs.uk/resources/collections/seven-steps-to-patient-safety/?entryid45=59787.
10. NPSA Five actions to improve patient safety reporting.[2010-8-6] Available from: URL:http://www.nrls.npsa.nhs.uk/resources/?entryid45=59903.
11. NPSA. National Framework for Reporting and Learning from Serious Incidents Requiring Investigation.[2010-8-16] Available from: URL: http://www.nrls.npsa.nhs.uk/resources/?entryid45=75173.
12. CIHI. The Development of a Canadian Medication Incident Reporting and Prevention System (CMIRPS) for Canada.[2010-10-4] Available from: URL: http://www.hc-sc.gc.ca.
13. Institute for Safe Medication Practices Canada (ISMP). Canadian Medication Incident Reporting and Prevention System. [2010-10-4] Available from: URL: www.ismp-canada.org.
14. NPSF. Advanced Incident Management System (AIMS).[2010-8-23] Available from: URL:http://www.apsf.net.au/products.php.
15. Isoft Health.iSOFT Solution Overview.[2010-8-30] Available from: URL:http://www.isofthealth.com/en/~/media/A776EC4BB2E945E4840F7896792BFBF9.ashx.
16. 台湾行政院卫生署. 台湾病人安全通报系统病人安全通报单（第五版）. [2010-11-2] Available from: URL: http://www.tpr.org.tw/dl/TPR_5(13)C.pdf.
17. 台湾行政院卫生署. 台湾病人安全通报系统介绍. [2010-10-4] Available from: URL: http://www.tpr.org.tw/index01.php.

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