異常 事件 通報 與 病人 安全 --Learning From Errors
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異常 事件 通報 與 病人 安全 --Learning From Errors. 財團法人醫院評鑑暨醫療品質策進會. 大綱. 通報與病人安全的關聯 為何要有通報 系統？ 飛航安全 V.S. 醫療安全 台灣 病人安全通報系統 簡介 101-102 年診所病人安全年度目標. Institute of Medicine 1999 報告. 每年約有 44,000~98,000 的美國人因為醫療錯誤死亡。 居當年十大死因 第八位 ( 高於乳癌、交通事故、愛滋病死亡的人數 ) 。 - PowerPoint PPT Presentation
Transcript of 異常 事件 通報 與 病人 安全 --Learning From Errors
()
--Learning From Errors
V.S.101-102
44,000~98,000() Safety is a critical first step in improving quality of care
Institute of Medicine 1999
To err is human, but errors can be prevented
Research has shown that a percentage of patients going thru our healthcare system are harmed
Situational FactorsLatent FailureActive FailureSafety BarrierAccident
()CHEESE()!CHEESE
.1030600()
Frank Bird. 1969
20041027WHO World Alliance for Patient Safety2005-2006
8910311117 SQ006, B747-400.83
SQ006,,83
B5SSWest CrossNP05R05L
,,.near miss,,near missalert10/
to improve patient safety by reducing the risk of harm through errors!
200311
TPRTPR (Taiwan Patient-safety Reporting system)
http://www.tpr.org.tw
12TPRhttp://www.tpr.org.tw13
TPR:(2005.01~2012.12)
Taiwan Patient safety Reporting systemTPR2004920124,611248,955201269859,7451.2.5.7.3.12. 11.10./4.9.6.8.//13.
1520052006200720082009201020112012()()()()()()()()17473,1054,5957,61810,56915,56916,77419,474 (31.0)(29.3)(28.0)(31.1)(29.0)(31.3)(29.3)(30.9)24182,7223,8456,46210,09413,58115,20716,586 (17.3)(25.7)(23.4)(26.4)(27.7)(27.3)(26.5)(26.3)33281,1302,7673,6636,1388,0999,6729,781 (13.6)(10.7)(16.9)(14.9)(16.8)(16.3)(16.9)(15.5)42441,1161,7152,0382,5983,3234,1854,511 (10.1)(10.5)(10.4)(8.3)(7.1)(6.7)(7.3)(7.2)52041,0051,5751,6132,4093,1593,9174,422 (8.5)(9.5)(9.6)(6.6)(6.6)(6.4)(6.9)(7.0)61835177669611,5171,8622,7792,452 (7.6)(4.9)(4.7)(3.9)(4.2)(3.7)(4.9)(3.9)71565053359401,2271,5431,6182,056 (6.5)(4.8)(2.0)(3.8)(3.4)(3.1)(2.8)(3.3)
17TPR(200520125)56,4841,91778143921513,82162,68644,0817,7541142,6587743242,00957,7142,6773411211372,8441,7990012201201,9428,21139040358979587710,0682,590165296228471963,1176,3812,07315112112345599,2865,3838,779172615854957915,65331,84026025666442841,22734,3461,69462162234231,86918300000118411,708402440167911,8711,57120373123163592,210174,60221,6463544,3591,7811,0619,987213,790
TPRhttp://www.tpr.org.tw84245
()/REPORTINGRCA
PDCAPlanDoCheckAnalysis
19
DemoralMorphine??
2005TPRDemoralMorphine
Morphine
23
101-102101-102New!!!
TPR
101-102
25Connolly C. BMJ 2000
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02-8964-3000 [email protected]:http://www.tpr.org.twwww.patientsafety.mohw.gov.twwww.tjcha.org.tw
