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KMID : 9000220160010220122
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NECA Research Report
2016 Volume.1 No. 2 p.1 ~ p.122
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Kim Su-Kyeong
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Abstract
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? Introduction
Since the US Institute of Medicine (IOM) published the report titled “To Err is Human: Building a Safer Health System” in 1999, there has been growing attention to patient safety globally. The report included the frequency of medical errors, classification type, and conceptualization; it also suggested development of a national-level reporting system for voluntary reporting by health and medical facilities and relevant professionals as one strategy to secure the health and medical system’s safety. After the report, the US established the Federal Drug Administration (FDA) medication error management system. The Department of Veterans Affairs and the National Aeronautics and Space Administration (NASA) worked together to develop a Patient Safety Reporting System (PSRS) based on the Aviation Safety Reporting System (ASRA); it is now the archetype for the current US patient safety information system.
Many other countries including the UK, Denmark, and Australia are making efforts to prevent and manage patient safety incidents by collecting and analyzing relevant data through various voluntary or compulsory systems. They established and operate patient safety systems with various training and research activities to encourage voluntary efforts. Korea enacted and proclaimed a patient safety act as of last January 28, with its main focus on the operation of a patient safety reporting training system. Such an infrastructure system to collect, analyze, and use relevant data can clearly identify information regarding patient safety incidents happening in Korean medical institutions and minimize further incidents by making improvements; its implementation can be the foundation to secure patient safety at the national level.
In addition, it is also important to enhance patient safety research in order to implement a system to collect and manage patient safety incident information, especially because Korea is in the beginning stages. According to the World Health Organization (WHO), the concept of patient safety is still unclear; research to collect related data is insufficient. In addition, improvements for patient safety require changes at every step of the health and medical system. Therefore, the WHO emphasizes strong national policies along with strategic execution plans.
Each country type has different research priorities to identify patient safety issues and take measures (WHO, 2009). Therefore, since Korea just enacted the patient safety act and is beginning its efforts at the national level, its priorities in identifying the issues and making improvements are different from other countries. When a patient safety related accident occurs, it is currently identified by only limited people within the medical institution; the information sharing is insufficient. Against this backdrop, it is not effective to decide to invest in identifying patient safety issues and making improvements based on the available Korean data or evidence. Instead, it is possible to gather experts’ opinions and make decisions, although there are gaps in information and experience. This will enable efforts made with limited resources and insufficient information to be more efficient.
Because there is a growing necessity to establish a patient safety information system with the enactment of the patient safety act, this study finds implications for the establishment of the Korean system by reviewing examples of other countries with patient safety related information systems and sets priorities in related research especially to investigate patient safety issues. To this end, we researched and analyzed details of patient safety reporting systems of other countries and compared and verified their characteristics; we reviewed detailed measures to establish a Korean patient safety information system for reporting, analysis, and feedback of patient safety accidents.
Moreover, we conducted a Delphi survey on the priorities of patient safety research among Korean experts based on the priorities previously defined by the WHO. This set the research priorities and identified their characteristics as a basis for more systematic and effective execution of patient safety research in Korea.
? Patient Safety Information System Operation by Country
I. Examples of Other Countries
Agency in Charge
The US operates patient safety organizations at the state level, centered on the Agency for Healthcare Research and Quality (AHRQ) under the Department of Health and Human Resources (HHS). In the meantime, Denmark, Australia, Norway, and the UK are operating relevant systems at the national level.
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KEYWORD
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Patient Safety, Patient Safety Reporting and learning System, Priority, Patient
Safety Research, Delphi
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