零惩罚报告在消毒供应中心不良事件处理中的应用

Application of zero penalty report on adverse events in disinfection supply center

目的探讨零惩罚报告在消毒供应中心不良事件处理中的应用。方法确认不良事件范围,建立零惩罚报告制度、规范其报告程序、培训消毒供应专业人员。将建立零惩罚报告制度前不良事件报告的2013年1~12月分为A组,其中2013年1~6月报告的不良事件数为A1组,7~12月为A2组,全年问卷调查为A3组;将建立零惩罚报告制度后不良事件报告的2014年1~12月作为B组,其中2014年1~6月报告的不良事件数为B1组,7~12月为B2组,全年问卷调查为B3组;分别比较组间、组内不良事件发生情况。结果 A组15件,B组21件,B组比A组增长了40%;B1组15件,B2组6件,B2组比B1组减少了60%。A3组23件,与A组15件比较,漏报了8件,漏报率53%,B3组21件与B组一致,漏报率0。组间、组内比较,差异具有统计学意义（P〈0.05）。结论消毒供应中心不良事件的判定、零惩罚上报及规范管理有助于减少漏报,及时发现和解决问题,可保障医疗安全和提高临床、手术服务的满意度。

Objective To discuss the application of zero penalty report on adverse events in disinfection supply center.Methods The adverse events was confirmed.The report system of zero penalty report and procedures were established.The staff of disinfection supply center was trained.The adverse events before zero penalty report system（January2013-December 2013）were selected as group A including group A1（January 2013-June 2013）and group A2（July 2013-December 2013）.The questionnaire survey of 2013 was group A3.The adverse events after zero penalty report system（January 2014-December 2014）were selected as group B including group B1（January 2014-June 2014）and group B2（July 2014-December 2014）.The questionnaire survey of 2014 was group B3.The adverse events of the groups were analyzed.Results The adverse events of group A were and group B were 15 cases and 21 cases.The adverse events of group B increased 40% compared with that of group A.The adverse events of group B1 and B2 were 15 cases and 6cases.The adverse events of group B2 decreased 60% compared with that of group B1.The adverse events of group A3 were 23cases.The underreporting rate of group A and group B were 53%（8Cases）and 0%（0cases）（P〈0.05）.Conclusion adverse events judgment,zero penalty report and standard management can decrease underreporting rate of adverse events,find and resolve the problems,ensure medical safety and increase degree of satisfaction.