保护机制在主动报告医疗不良事件管理中的探讨

目的探讨保护机制在医疗不良事件主动报告中的作用。方法通过建立网络直报、质控科直接介入、保密信息、减轻处罚等措施保护报告人。比较保护机制引入前后主动报告不良事件例数、严重不良事件报告例数、当事人主动报告不良事件例数、不良事件报告类型及报告人员岗位的变化等。结果2009年1-6月与2008年同期比较，主动报告不良事件例数由109例增加到438例；严重不良事件报告的例数由14例增加到70例；当事人主动报告医疗不良事件的例数由68例上升到343例；不良事件主动报告的类型及报告人员岗位发生了明显的变化，原本不太愿意报告的医疗处置事件例数快速上升。结论保护机制使医院不良事件主动报告例数明显增加，严重不良事件报告的例数也明显增加，当事人能主动报告医疗不良事件的例数快速增加，不良事件报告的类型及报告人员岗位变化明显，可见保护机制的引入较好地促进了医疗不良事件的主动报告。

Protection Mechanism in the Management of Active Reporting of Medical Adverse Events

Objective To explore the effect of protective mechanism in active reporting of adverse events in hospital. Method The reporter was protected by several measures; including network direct reporting, intervening of the quality control office, keeping information confidentiality, correcting concept and establishing justice culture, etc. The changes before and after the practice of protective mechanism were compared which included the number of active reporting of medical adverse events, the number of serious adverse events, the number reported by the party, the type of the events and change of reporters job. Result Compared the adverse events reported actively during June 2008 with that of the same time of 2009, the number of the reported ad- verse events increased from 109 to 438, the number of serious events increased from 14 to 70, the number reported by the parties increased from 68 to 343. Meanwhile, the type of the adverse events changed obviously, and the number of events not likely to be reported before increased rapidly. Conclusion The protective mechanism led to the obvious increase of the number of reporting the adverse events, the serious events, the parties reporting, and the type of adverse events and jobs of reporters changed obviously. The protective mechanism reinforces the active reporting of adverse events in hospital.