病人安全通報系統運作與現況之質性研究

目的：本研究主要目的為探討某一教學醫院病人安全通報系統之運作與現況。方法：本質性研究為探索性研究，採立意抽樣，選取某一教學醫院為研究對象，於2007年7月至9月，以「訪談法」（n＝5）和「焦點團體法」（n＝43）收集實證資料，共有48位受訪者。結果：根據深度訪談及焦點團體資料，進行命題式分析的結果，主要有通報系統的功能、通報流程、品質改善活動、領導與組織文化、管理者的角色、通報障礙、及回饋機制等七個命題，其中，受訪醫院於異常事件通報上所面臨的主要障礙有：1.工作忙碌，由於無法馬上結束或暫緩手邊的工作，導致無法立即的通報；2.通報壓力，通報者害怕同儕或主管的責備，以及通報後所需面對的後果，導致當異常事件發生時不願通報；3.擔心異常事件演變成醫療糾紛；4.成員對於異常通報所持的價值與心態；5.對通報系統的不了解。結論：在鼓勵通報上，保護通報者尤為重要，多數人都害怕被懲罰，因此，當管理者抱持著保護的心態來支持通報者，將會提升通報系統的使用率。

關鍵字

通報系統；病人安全；個案研究

並列摘要

Objectives: This study investigated the operation and current status of the patient safety reporting system in a teaching hospital. Methods: A teaching hospital was purposefully chosen as the study subject. This exploratory study was a qualitative one in which data were collected from in-depth interviews (n=5) and focus groups (n=43) from July to September 2007 for a total of 48 participants. Results: By using thematic analysis of the responses from the in-depth interviews and focus groups, we extracted seven themes: functions of the reporting system, reporting procedures, approaches to quality improvement, leadership and organizational culture, managers' roles, barriers to reporting, and feedback mechanisms. Barriers to reporting incidents in the hospital were (1) Staff were too busy to suspend or terminate their work at once and were unable to report incidents immediately. (2) Reporters were afraid of being blamed by their colleagues or managers and of facing the consequences of reporting. Such pressures made them unwilling to report. (3) Staff were afraid of the medical disputes resulting from incidents. (4) The values and attitudes of staff make themselves not to report incidents. (5) There was insufficient understanding of the reporting system. Conclusions: Managers' protection of reporters is vital when encouraging staff to report incidents as most staff are afraid of being punished. If managers believed that they should protect reporters, then that would promote the use of the reporting system.

並列關鍵字

Reporting System ； Patient Safety ； Case Study

參考文獻

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