메뉴 건너뛰기




Volumn 26, Issue 2, 2017, Pages 150-163

International recommendations for national patient safety incident reporting systems: An expert Delphi consensus-building process

Author keywords

Health policy; Incident reporting; Patient safety; Safety culture; Significant event analysis, critical incident review

Indexed keywords

ARTICLE; CLINICAL PRACTICE; CONSENSUS DEVELOPMENT; DELPHI STUDY; HEALTH CARE SURVEY; HUMAN; INCIDENT REPORT; PATIENT MONITORING; PATIENT SAFETY; SEMI STRUCTURED INTERVIEW; CONSENSUS; INFORMATION PROCESSING; INTERNATIONAL COOPERATION; INTERVIEW; MEDICAL ERROR; ORGANIZATION AND MANAGEMENT; PROCEDURES; RISK MANAGEMENT; STATISTICS AND NUMERICAL DATA;

EID: 85011564416     PISSN: 20445415     EISSN: None     Source Type: Journal    
DOI: 10.1136/bmjqs-2015-004456     Document Type: Article
Times cited : (98)

References (131)
  • 3
    • 0347403555 scopus 로고    scopus 로고
    • Applying the lessons of high risk industries to health care
    • Hudson P. Applying the lessons of high risk industries to health care. Qual Saf Health Care 2003; 12(Suppl 1): i7-12
    • (2003) Qual Saf Health Care , vol.12 , pp. i7-12
    • Hudson, P.1
  • 5
    • 33845724544 scopus 로고    scopus 로고
    • An integrated framework for safety, quality and risk management: An information and incident management system based on a universal patient safety classification
    • Runciman WB, Williamson JA, Deakin A, et al. An integrated framework for safety, quality and risk management: an information and incident management system based on a universal patient safety classification. Qual Saf Health Care 2006; 15(Suppl 1): i82-90
    • (2006) Qual Saf Health Care , vol.15 , pp. i82-90
    • Runciman, W.B.1    Williamson, J.A.2    Deakin, A.3
  • 6
    • 0345471068 scopus 로고    scopus 로고
    • Evaluation of two methods for quality improvement in intensive care: Facilitated incident monitoring and retrospective medical chart review
    • Beckmann U, Bohringer C, Carless R, et al. Evaluation of two methods for quality improvement in intensive care: facilitated incident monitoring and retrospective medical chart review. Crit Care Med 2003; 31: 1006-11
    • (2003) Crit Care Med , vol.31 , pp. 1006-1011
    • Beckmann, U.1    Bohringer, C.2    Carless, R.3
  • 7
    • 26444580208 scopus 로고    scopus 로고
    • Violence in health care: The contribution of the Australian patient safety foundation to incident monitoring and analysis
    • Benveniste KA, Hibbert PD, Runciman WB. Violence in health care: the contribution of The Australian Patient Safety Foundation to incident monitoring and analysis. Med J Aust 2005; 183: 348-51
    • (2005) Med J Aust , vol.183 , pp. 348-351
    • Benveniste, K.A.1    Hibbert, P.D.2    Runciman, W.B.3
  • 8
    • 85011598014 scopus 로고    scopus 로고
    • NRLS Secondary NRLS Quarterly Data Workbook up to December 2014
    • NRLS. NRLS Quarterly Data Workbook up to December 2014. Secondary NRLS Quarterly Data Workbook up to December 2014. 2014. http://www.nrls.npsa.nhs.uk/resources/collections/quarterly-data-summaries/?entryid45=135253
    • (2014) NRLS Quarterly Data Workbook Up to December 2014
  • 9
    • 77953793667 scopus 로고    scopus 로고
    • The helsinki declaration on patient safety in anaesthesiology
    • Mellin-Olsen J, Staender S, Whitaker DK, et al. The Helsinki Declaration on Patient Safety in Anaesthesiology. Eur J Anaesthesiol 2010; 27: 592-7
    • (2010) Eur J Anaesthesiol , vol.27 , pp. 592-597
    • Mellin-Olsen, J.1    Staender, S.2    Whitaker, D.K.3
  • 10
    • 84940030059 scopus 로고    scopus 로고
    • State-mandated reporting of health care-associated infections in the united states: Trends over time
    • Herzig CT, Reagan J, Pogorzelska-Maziarz M, et al. State-mandated reporting of health care-associated infections in the United States: trends over time. Am J Med Qual 2015; 30: 417-24
    • (2015) Am J Med Qual , vol.30 , pp. 417-424
    • Herzig, C.T.1    Reagan, J.2    Pogorzelska-Maziarz, M.3
  • 11
    • 0027674018 scopus 로고
    • The australian incident monitoring study errors, incidents and accidents in anaesthetic practice
    • Runciman WB, Sellen A, Webb RK, et al. The Australian Incident Monitoring Study. Errors, incidents and accidents in anaesthetic practice. Anaesth Intensive Care 1993; 21: 506-19
    • (1993) Anaesth Intensive Care , vol.21 , pp. 506-519
    • Runciman, W.B.1    Sellen, A.2    Webb, R.K.3
  • 12
    • 84879880167 scopus 로고    scopus 로고
    • Patient safety improvements in radiation treatment through 5 years of incident learning
    • Clark BG, Brown RJ, Ploquin J, et al. Patient safety improvements in radiation treatment through 5 years of incident learning. Pract Radiat Oncol 2013; 3: 157-63
    • (2013) Pract Radiat Oncol , vol.3 , pp. 157-163
    • Clark, B.G.1    Brown, R.J.2    Ploquin, J.3
  • 13
    • 84903317885 scopus 로고    scopus 로고
    • Patient-safety-related hospital deaths in England: Thematic analysis of incidents reported to a national database 2010-2012
    • Donaldson LJ, Panesar SS, Darzi A. Patient-safety-related hospital deaths in England: thematic analysis of incidents reported to a national database, 2010-2012. PLoS Med 2014; 11: e1001667
    • (2014) Plos Med , vol.11 , pp. e1001667
    • Donaldson, L.J.1    Panesar, S.S.2    Darzi, A.3
  • 14
    • 79956213586 scopus 로고    scopus 로고
    • Missing clinical information in NHS hospital outpatient clinics: Prevalence, causes and effects on patient care
    • Burnett SJ, Deelchand V, Franklin BD, et al. Missing clinical information in NHS hospital outpatient clinics: prevalence, causes and effects on patient care. BMC Health Serv Res 2011; 11: 114
    • (2011) BMC Health Serv Res , vol.11 , pp. 114
    • Burnett, S.J.1    Deelchand, V.2    Franklin, B.D.3
  • 15
    • 33644805464 scopus 로고    scopus 로고
    • Integrating the intensive care unit safety reporting system with existing incident reporting systems
    • Thompson DA, Lubomski L, Holzmueller C, et al. Integrating the intensive care unit safety reporting system with existing incident reporting systems. Jt Comm J Qual Patient Saf 2005; 31: 585-93
    • (2005) Jt Comm J Qual Patient Saf , vol.31 , pp. 585-593
    • Thompson, D.A.1    Lubomski, L.2    Holzmueller, C.3
  • 16
    • 0036728580 scopus 로고    scopus 로고
    • An organisation with a memory
    • Donaldson L. An organisation with a memory. Clin Med (Lond) 2002; 2: 452-7
    • (2002) Clin Med (Lond , vol.2 , pp. 452-457
    • Donaldson, L.1
  • 17
    • 0032507502 scopus 로고    scopus 로고
    • Framework for analysing risk and safety in clinical medicine
    • Vincent C, Taylor-Adams S, Stanhope N. Framework for analysing risk and safety in clinical medicine. Bmj 1998; 316: 1154-7
    • (1998) Bmj , vol.316 , pp. 1154-1157
    • Vincent, C.1    Taylor-Adams, S.2    Stanhope, N.3
  • 18
    • 0029319485 scopus 로고
    • Understanding adverse events: Human factors
    • Reason J. Understanding adverse events: human factors. Qual Health Care 1995; 4: 80-9
    • (1995) Qual Health Care , vol.4 , pp. 80-89
    • Reason, J.1
  • 20
    • 84955323245 scopus 로고    scopus 로고
    • Patient safety incident reporting: A qualitative study of thoughts and perceptions of experts 15 years after 'to err is human
    • Mitchell I, Schuster A, Smith K, et al. Patient safety incident reporting: a qualitative study of thoughts and perceptions of experts 15 years after 'To Err is Human'. BMJ Qual Saf 2016; 25: 92-9
    • (2016) BMJ Qual Saf , vol.25 , pp. 92-99
    • Mitchell, I.1    Schuster, A.2    Smith, K.3
  • 21
    • 84875133295 scopus 로고    scopus 로고
    • Trends in adverse events over time: Why are we not improving?
    • Shojania KG, Thomas EJ. Trends in adverse events over time: why are we not improving? BMJ Qual Saf 2013; 22: 273-7
    • (2013) BMJ Qual Saf , vol.22 , pp. 273-277
    • Shojania, K.G.1    Thomas, E.J.2
  • 23
    • 57349175943 scopus 로고    scopus 로고
    • Is health care getting safer?
    • Vincent C, Aylin P, Franklin BD, et al. Is health care getting safer? BMJ 2008; 337: a2426
    • (2008) BMJ , vol.337 , pp. a2426
    • Vincent, C.1    Aylin, P.2    Franklin, B.D.3
  • 24
    • 33846305099 scopus 로고    scopus 로고
    • Sensitivity of routine system for reporting patient safety incidents in an NHS hospital: Retrospective patient case note review
    • Sari AB, Sheldon TA, Cracknell A, et al. Sensitivity of routine system for reporting patient safety incidents in an NHS hospital: retrospective patient case note review. BMJ 2007; 334: 79
    • (2007) BMJ , vol.334 , pp. 79
    • Sari, A.B.1    Sheldon, T.A.2    Cracknell, A.3
  • 25
    • 84971585627 scopus 로고
    • Consensus methods for medical and health services research
    • Jones J, Hunter D. Consensus methods for medical and health services research. BMJ 1995; 311: 376-80
    • (1995) BMJ , vol.311 , pp. 376-380
    • Jones, J.1    Hunter, D.2
  • 26
    • 58849134223 scopus 로고    scopus 로고
    • Towards an International Classification for Patient Safety: Key concepts and terms
    • Runciman W, Hibbert P, Thomson R, et al. Towards an International Classification for Patient Safety: key concepts and terms. Int J Qual Health Care 2009; 21: 18-26
    • (2009) Int J Qual Health Care , vol.21 , pp. 18-26
    • Runciman, W.1    Hibbert, P.2    Thomson, R.3
  • 27
    • 84965027194 scopus 로고    scopus 로고
    • 2nd edn. Oxford, UK: BMJ Publishing Group Limited Wiley-Blackwell Elsevier Limited
    • Vincent C. Patient Safety. 2nd edn. Oxford, UK: BMJ Publishing Group Limited, Wiley-Blackwell, Elsevier Limited, 2010
    • (2010) Patient Safety
    • Vincent, C.1
  • 28
    • 0037244466 scopus 로고    scopus 로고
    • Measuring errors and adverse events in health care
    • Thomas EJ, Petersen LA. Measuring errors and adverse events in health care. J Gen Intern Med 2003; 18: 61-7
    • (2003) J Gen Intern Med , vol.18 , pp. 61-67
    • Thomas, E.J.1    Petersen, L.A.2
  • 29
    • 4243199175 scopus 로고    scopus 로고
    • Event reporting to a primary care patient safety reporting system: A report from the ASIPS collaborative
    • Fernald DH, Pace WD, Harris DM, et al. Event reporting to a primary care patient safety reporting system: a report from the ASIPS collaborative. Ann Fam Med 2004; 2: 327-32
    • (2004) Ann Fam Med , vol.2 , pp. 327-332
    • Fernald, D.H.1    Pace, W.D.2    Harris, D.M.3
  • 30
    • 84880571911 scopus 로고    scopus 로고
    • Training faculty in nontechnical skill assessment: National guidelines on program requirements
    • Hull L, Arora S, Symons NR, et al. Training faculty in nontechnical skill assessment: national guidelines on program requirements. Ann Surg 2013; 258: 370-5
    • (2013) Ann Surg , vol.258 , pp. 370-375
    • Hull, L.1    Arora, S.2    Symons, N.R.3
  • 33
    • 0021167119 scopus 로고
    • Consensus methods: Characteristics and guidelines for use
    • Fink A, Kosecoff J, Chassin M, et al. Consensus methods: characteristics and guidelines for use. Am J Public Health 1984; 74: 979-83
    • (1984) Am J Public Health , vol.74 , pp. 979-983
    • Fink, A.1    Kosecoff, J.2    Chassin, M.3
  • 34
    • 78049490992 scopus 로고    scopus 로고
    • Patient safety incidents involving neuromuscular blockade: Analysis of the uk national reporting and learning system data from 2006 to 2008
    • Arnot-Smith J, Smith AF. Patient safety incidents involving neuromuscular blockade: analysis of the UK National Reporting and Learning System data from 2006 to 2008. Anaesthesia 2010; 65: 1106-13
    • (2010) Anaesthesia , vol.65 , pp. 1106-1113
    • Arnot-Smith, J.1    Smith, A.F.2
  • 35
    • 84896859744 scopus 로고    scopus 로고
    • National critical incident reporting systems relevant to anaesthesia: A European survey
    • Reed S, Arnal D, Frank O, et al. National critical incident reporting systems relevant to anaesthesia: a European survey. Br J Anaesth 2014; 112: 546-55
    • (2014) Br J Anaesth , vol.112 , pp. 546-555
    • Reed, S.1    Arnal, D.2    Frank, O.3
  • 36
    • 79955868756 scopus 로고    scopus 로고
    • An analysis of critical incidents relevant to pediatric anesthesia reported to the UK national reporting and learning system 2006-2008
    • MacLennan AI, Smith AF. An analysis of critical incidents relevant to pediatric anesthesia reported to the UK National Reporting and Learning System, 2006-2008. Paediatr Anaesth 2011; 21: 841-7
    • (2011) Paediatr Anaesth , vol.21 , pp. 841-847
    • Maclennan, A.I.1    Smith, A.F.2
  • 37
    • 17144374917 scopus 로고    scopus 로고
    • The barrow-in-furness legionnaires' outbreak: Qualitative study of the hospital response and the role of the major incident plan
    • Smith AF, Wild C, Law J. The Barrow-in-Furness legionnaires' outbreak: qualitative study of the hospital response and the role of the major incident plan. Emerg Med J 2005; 22: 251-5
    • (2005) Emerg Med J , vol.22 , pp. 251-255
    • Smith, A.F.1    Wild, C.2    Law, J.3
  • 38
    • 74949130941 scopus 로고    scopus 로고
    • National critical incident reporting: Improving patient safety
    • Smith AF, Mahajan RP. National critical incident reporting: improving patient safety. Br J Anaesth 2009; 103: 623-5
    • (2009) Br J Anaesth , vol.103 , pp. 623-625
    • Smith, A.F.1    Mahajan, R.P.2
  • 39
    • 34247187482 scopus 로고    scopus 로고
    • Incident reporting schemes and the need for a good story
    • Rooksby J, Gerry RM, Smith AF. Incident reporting schemes and the need for a good story. Int J Med Inform 2007; 76 (Suppl 1): S205-11
    • (2007) Int J Med Inform , vol.76 , pp. S205-S211
    • Rooksby, J.1    Gerry, R.M.2    Smith, A.F.3
  • 40
    • 77953299956 scopus 로고    scopus 로고
    • Identifying systemic safety signals following intravitreal bevacizumab: Systematic review of the literature and the canadian adverse drug reaction database
    • Micieli JA, Micieli A, Smith AF. Identifying systemic safety signals following intravitreal bevacizumab: systematic review of the literature and the Canadian Adverse Drug Reaction Database. Can J Ophthalmol 2010; 45: 231-8
    • (2010) Can J Ophthalmol , vol.45 , pp. 231-238
    • Micieli, J.A.1    Micieli, A.2    Smith, A.F.3
  • 41
    • 33847392867 scopus 로고    scopus 로고
    • Stopping the error cascade: A report on ameliorators from the ASIPS collaborative
    • Parnes B, Fernald D, Quintela J, et al. Stopping the error cascade: a report on ameliorators from the ASIPS collaborative. Qual Saf Health Care 2007; 16: 12-16
    • (2007) Qual Saf Health Care , vol.16 , pp. 12-16
    • Parnes, B.1    Fernald, D.2    Quintela, J.3
  • 42
    • 84880663862 scopus 로고    scopus 로고
    • A visual computer interface concept for making error reporting useful at the point of care
    • In: Henriksen K Battles JB Keyes MA et al eds Assessment). Rockville MD
    • Singh R, Pace W, Singh A, et al. A visual computer interface concept for making error reporting useful at the point of care. In: Henriksen K, Battles JB, Keyes MA, et al., eds. Advances in Patient Safety: New Directions and Alternative Approaches (Vol. 1: Assessment). Rockville (MD), 2008: http://www.ncbi. nlm.nih.gov/books/NBK43644/
    • (2008) Advances in Patient Safety New Directions and Alternative Approaches , vol.1
    • Singh, R.1    Pace, W.2    Singh, A.3
  • 43
    • 39149086115 scopus 로고    scopus 로고
    • A concept for a visual computer interface to make error taxonomies useful at the point of primary care
    • Singh R, Pace W, Singh S, et al. A concept for a visual computer interface to make error taxonomies useful at the point of primary care. Inform Prim Care 2007; 15: 221-9
    • (2007) Inform Prim Care , vol.15 , pp. 221-229
    • Singh, R.1    Pace, W.2    Singh, S.3
  • 45
    • 78449273007 scopus 로고    scopus 로고
    • Field test results of a new ambulatory care medication error and adverse drug event reporting system-meaders
    • Hickner J, Zafar A, Kuo GM, et al. Field test results of a new ambulatory care Medication Error and Adverse Drug Event Reporting System-MEADERS. Ann Fam Med 2010; 8: 517-25
    • (2010) Ann Fam Med , vol.8 , pp. 517-525
    • Hickner, J.1    Zafar, A.2    Kuo, G.M.3
  • 46
    • 77953838470 scopus 로고    scopus 로고
    • Developing a taxonomy for coding ambulatory medical errors: A report from the asips collaborative
    • In: Henriksen K, Battles JB, Marks ES, et al, eds Concepts and Methodology). Rockville MD
    • Pace WD, Fernald DH, Harris DM, et al. Developing a Taxonomy for Coding Ambulatory Medical Errors: A Report from the ASIPS Collaborative. In: Henriksen K, Battles JB, Marks ES, et al, eds. Advances in Patient Safety: From Research to Implementation (Volume 2: Concepts and Methodology). Rockville, MD, 2005: http://www.ncbi.nlm. nih.gov/books/NBK20493/
    • (2005) Advances in Patient Safety: From Research to Implementation , vol.2
    • Pace, W.D.1    Fernald, D.H.2    Harris, D.M.3
  • 47
    • 0242496179 scopus 로고    scopus 로고
    • Database design to ensure anonymous study of medical errors: A report from the ASIPS Collaborative
    • Pace WD, Staton EW, Higgins GS, et al. Database design to ensure anonymous study of medical errors: a report from the ASIPS Collaborative. J Am Med Inform Assoc 2003; 10: 531-40
    • (2003) J Am Med Inform Assoc , vol.10 , pp. 531-540
    • Pace, W.D.1    Staton, E.W.2    Higgins, G.S.3
  • 48
    • 78650436396 scopus 로고    scopus 로고
    • An analysis of computer-related patient safety incidents to inform the development of a classification
    • Magrabi F, Ong MS, Runciman W, et al. An analysis of computer-related patient safety incidents to inform the development of a classification. J Am Med Inform Assoc 2010; 17: 663-70
    • (2010) J Am Med Inform Assoc , vol.17 , pp. 663-670
    • Magrabi, F.1    Ong, M.S.2    Runciman, W.3
  • 49
    • 0030012625 scopus 로고    scopus 로고
    • The australian incident monitoring study in intensive care: Aims-icu an analysis of the first year of reporting
    • Beckmann U, Baldwin I, Hart GK, et al. The Australian Incident Monitoring Study in Intensive Care: AIMS-ICU. An analysis of the first year of reporting. Anaesth Intensive Care 1996; 24: 320-9
    • (1996) Anaesth Intensive Care , vol.24 , pp. 320-329
    • Beckmann, U.1    Baldwin, I.2    Hart, G.K.3
  • 50
    • 0029927154 scopus 로고    scopus 로고
    • The australian incident monitoring study in intensive care: Aims-icu the development and evaluation of an incident reporting system in intensive care
    • Beckmann U, West LF, Groombridge GJ, et al. The Australian Incident Monitoring Study in Intensive Care: AIMS-ICU. The development and evaluation of an incident reporting system in intensive care. Anaesth Intensive Care 1996; 24: 314-19
    • (1996) Anaesth Intensive Care , vol.24 , pp. 314-319
    • Beckmann, U.1    West, L.F.2    Groombridge, G.J.3
  • 51
    • 79959661552 scopus 로고    scopus 로고
    • Mapping the limits of safety reporting systems in health care-what lessons can we actually learn?
    • Thomas MJ, Schultz TJ, Hannaford N, et al. Mapping the limits of safety reporting systems in health care-what lessons can we actually learn? Med J Aust 2011; 194: 635-9
    • (2011) Med J Aust , vol.194 , pp. 635-639
    • Thomas, M.J.1    Schultz, T.J.2    Hannaford, N.3
  • 52
    • 84926231542 scopus 로고    scopus 로고
    • Establishing national medical imaging incident reporting systems: Issues and challenges
    • Jones DN, Benveniste KA, Schultz TJ, et al. Establishing national medical imaging incident reporting systems: issues and challenges. J Am Coll Radiol 2010; 7: 582-92
    • (2010) J Am Coll Radiol , vol.7 , pp. 582-592
    • Jones, D.N.1    Benveniste, K.A.2    Schultz, T.J.3
  • 53
    • 34250876829 scopus 로고    scopus 로고
    • Evaluation of an intervention aimed at improving voluntary incident reporting in hospitals
    • Evans SM, Smith BJ, Esterman A, et al. Evaluation of an intervention aimed at improving voluntary incident reporting in hospitals. Qual Saf Health Care 2007; 16: 169-75
    • (2007) Qual Saf Health Care , vol.16 , pp. 169-175
    • Evans, S.M.1    Smith, B.J.2    Esterman, A.3
  • 54
    • 0036752174 scopus 로고    scopus 로고
    • Lessons from the australian patient safety foundation: Setting up a national patient safety surveillance system-is this the right model?
    • Runciman WB. Lessons from The Australian Patient Safety Foundation: setting up a national patient safety surveillance system-is this the right model? Qual Saf Health Care 2002; 11: 246-51
    • (2002) Qual Saf Health Care , vol.11 , pp. 246-251
    • Runciman, W.B.1
  • 55
    • 0033635673 scopus 로고    scopus 로고
    • Inadequate pre-operative evaluation and preparation: A review of 197 reports from the Australian incident monitoring study
    • Kluger MT, Tham EJ, Coleman NA, et al. Inadequate pre-operative evaluation and preparation: a review of 197 reports from The Australian incident monitoring study. Anaesthesia 2000; 55: 1173-8
    • (2000) Anaesthesia , vol.55 , pp. 1173-1178
    • Kluger, M.T.1    Tham, E.J.2    Coleman, N.A.3
  • 56
    • 0027672715 scopus 로고
    • The australian incident monitoring study crisis management-validation of an algorithm by analysis of 2000 incident reports
    • Runciman WB, Webb RK, Klepper ID, et al. The Australian Incident Monitoring Study. Crisis management-validation of an algorithm by analysis of 2000 incident reports. Anaesth Intensive Care 1993; 21: 579-92
    • (1993) Anaesth Intensive Care , vol.21 , pp. 579-592
    • Runciman, W.B.1    Webb, R.K.2    Klepper, I.D.3
  • 57
    • 0027452158 scopus 로고
    • The australian incident monitoring study: An analysis of 2000 incident reports
    • Webb RK, Currie M, Morgan CA, et al. The Australian Incident Monitoring Study: an analysis of 2000 incident reports. Anaesth Intensive Care 1993; 21: 520-8
    • (1993) Anaesth Intensive Care , vol.21 , pp. 520-528
    • Webb, R.K.1    Currie, M.2    Morgan, C.A.3
  • 58
    • 0142244150 scopus 로고    scopus 로고
    • Does full disclosure of medical errors affect malpractice liability? the jury is still out
    • Kachalia A, Shojania KG, Hofer TP, et al. Does full disclosure of medical errors affect malpractice liability? The jury is still out. Jt Comm J Qual Saf 2003; 29: 503-11
    • (2003) Jt Comm J Qual Saf , vol.29 , pp. 503-511
    • Kachalia, A.1    Shojania, K.G.2    Hofer, T.P.3
  • 59
    • 61449150551 scopus 로고    scopus 로고
    • The frustrating case of incident-reporting systems
    • Shojania KG. The frustrating case of incident-reporting systems. Qual Saf Health Care 2008; 17: 400-2
    • (2008) Qual Saf Health Care , vol.17 , pp. 400-402
    • Shojania, K.G.1
  • 60
    • 14944364957 scopus 로고    scopus 로고
    • The faces of errors: A case-based approach to educating providers, policymakers, and the public about patient safety
    • Wachter RM, Shojania KG. The faces of errors: a case-based approach to educating providers, policymakers, and the public about patient safety. Jt Comm J Qual Saf 2004; 30: 665-70
    • (2004) Jt Comm J Qual Saf , vol.30 , pp. 665-670
    • Wachter, R.M.1    Shojania, K.G.2
  • 61
    • 84862992343 scopus 로고    scopus 로고
    • AHRQ webm&m-online medical error reporting and analysis
    • In: Henriksen K Battles JB Marks ES et al eds Programs, Tools, and Products). Rockville MD
    • Wachter RM, Shojania KG, Minichiello T, et al. AHRQ WebM&M-Online Medical Error Reporting and Analysis. In: Henriksen K, Battles JB, Marks ES, et al, eds. Advances in Patient Safety: From Research to Implementation (Volume 4: Programs, Tools, and Products). Rockville, MD, 2005: http://www.ncbi.nlm.nih.gov/books/NBK20609/
    • (2005) Advances in Patient Safety: From Research to Implementation , vol.4
    • Wachter, R.M.1    Shojania, K.G.2    Minichiello, T.3
  • 62
    • 0036656640 scopus 로고    scopus 로고
    • Understanding medical error and improving patient safety in the inpatient setting
    • Shojania KG, Wald H, Gross R. Understanding medical error and improving patient safety in the inpatient setting. Med Clin North Am 2002; 86: 847-67
    • (2002) Med Clin North Am , vol.86 , pp. 847-867
    • Shojania, K.G.1    Wald, H.2    Gross, R.3
  • 63
    • 85047687808 scopus 로고    scopus 로고
    • Classifying laboratory incident reports to identify problems that jeopardize patient safety
    • Astion ML, Shojania KG, Hamill TR, et al. Classifying laboratory incident reports to identify problems that jeopardize patient safety. Am J Clin Pathol 2003; 120: 18-26
    • (2003) Am J Clin Pathol , vol.120 , pp. 18-26
    • Astion, M.L.1    Shojania, K.G.2    Hamill, T.R.3
  • 64
    • 77952984566 scopus 로고    scopus 로고
    • Patient safety matters: Reducing the risks of nasogastric tubes
    • Yardley IE, Donaldson LJ. Patient safety matters: reducing the risks of nasogastric tubes. Clin Med (Lond) 2010; 10: 228-30
    • (2010) Clin Med (Lond , vol.10 , pp. 228-230
    • Yardley, I.E.1    Donaldson, L.J.2
  • 65
    • 78249253921 scopus 로고    scopus 로고
    • Establishing a global learning community for incident-reporting systems
    • Pham JC, Gianci S, Battles J, et al. Establishing a global learning community for incident-reporting systems. Qual Saf Health Care 2010; 19: 446-51
    • (2010) Qual Saf Health Care , vol.19 , pp. 446-451
    • Pham, J.C.1    Gianci, S.2    Battles, J.3
  • 66
    • 80755168616 scopus 로고    scopus 로고
    • Toward safer care: Reporting systems, checklists and process standardization
    • Donaldson L. Toward safer care: reporting systems, checklists and process standardization. Journal 2011; 77: b123
    • (2011) Journal , vol.77 , pp. b123
    • Donaldson, L.1
  • 67
    • 84858259470 scopus 로고    scopus 로고
    • Alcohol skin preparation causes surgical fires
    • Rocos B, Donaldson LJ. Alcohol skin preparation causes surgical fires. Ann R Coll Surg Engl 2012; 94: 87-9
    • (2012) Ann R Coll Surg Engl , vol.94 , pp. 87-89
    • Rocos, B.1    Donaldson, L.J.2
  • 68
    • 0029126090 scopus 로고
    • The reporting of in-patient suicides: Identifying the problem
    • Blain PA, Donaldson LJ. The reporting of in-patient suicides: identifying the problem. Public health 1995; 109: 293-301
    • (1995) Public Health , vol.109 , pp. 293-301
    • Blain, P.A.1    Donaldson, L.J.2
  • 69
    • 80054903397 scopus 로고    scopus 로고
    • Improving RCA performance: The cornerstone award and the power of positive reinforcement
    • Bagian JP, King BJ, Mills PD, et al. Improving RCA performance: the Cornerstone Award and the power of positive reinforcement. BMJ Qual Saf 2011; 20: 974-82
    • (2011) BMJ Qual Saf , vol.20 , pp. 974-982
    • Bagian, J.P.1    King, B.J.2    Mills, P.D.3
  • 70
    • 0036884704 scopus 로고    scopus 로고
    • System innovation: Veterans health administration national center for patient safety
    • John M Eisenberg Patient Safety Awards
    • Heget JR, Bagian JP, Lee CZ, et al. John M. Eisenberg Patient Safety Awards. System innovation: Veterans Health Administration National Center for Patient Safety. Jt Comm J Qual Improv 2002; 28: 660-5
    • (2002) Jt Comm J Qual Improv , vol.28 , pp. 660-665
    • Heget, J.R.1    Bagian, J.P.2    Lee, C.Z.3
  • 71
    • 0035486819 scopus 로고    scopus 로고
    • Developing and deploying a patient safety program in a large health care delivery system: You can't fix what you don't know about
    • Bagian JP, Lee C, Gosbee J, et al. Developing and deploying a patient safety program in a large health care delivery system: you can't fix what you Don't know about. Jt Comm J Qual Improv 2001; 27: 522-32
    • (2001) Jt Comm J Qual Improv , vol.27 , pp. 522-532
    • Bagian, J.P.1    Lee, C.2    Gosbee, J.3
  • 72
    • 0036782125 scopus 로고    scopus 로고
    • The Veterans Affairs root cause analysis system in action
    • Bagian JP, Gosbee J, Lee CZ, et al. The Veterans Affairs root cause analysis system in action. Jt Comm J Qual Improv 2002; 28: 531-45
    • (2002) Jt Comm J Qual Improv , vol.28 , pp. 531-545
    • Bagian, J.P.1    Gosbee, J.2    Lee, C.Z.3
  • 73
    • 0034327887 scopus 로고    scopus 로고
    • Developing a culture of safety in the veterans health administration
    • Weeks WB, Bagian JP. Developing a culture of safety in the Veterans Health Administration. Eff Clin Pract 2000; 3: 270-6
    • (2000) Eff Clin Pract , vol.3 , pp. 270-276
    • Weeks, W.B.1    Bagian, J.P.2
  • 74
    • 33645749516 scopus 로고    scopus 로고
    • Patient safety: Lessons learned
    • Bagian JP. Patient safety: lessons learned. Pediatr Radiol 2006; 36: 287-90
    • (2006) Pediatr Radiol , vol.36 , pp. 287-290
    • Bagian, J.P.1
  • 75
    • 39349117321 scopus 로고    scopus 로고
    • Effective interventions and implementation strategies to reduce adverse drug events in the veterans affairs (va) system
    • Mills PD, Neily J, Kinney LM, et al. Effective interventions and implementation strategies to reduce adverse drug events in the Veterans Affairs (VA) system. Qual Saf Health Care 2008; 17: 37-46
    • (2008) Qual Saf Health Care , vol.17 , pp. 37-46
    • Mills, P.D.1    Neily, J.2    Kinney, L.M.3
  • 76
    • 83155163774 scopus 로고    scopus 로고
    • Effects on incident reporting after educating residents in patient safety: A controlled study
    • Jansma JD, Wagner C, ten Kate RW, et al. Effects on incident reporting after educating residents in patient safety: a controlled study. BMC Health Serv Res 2011; 11: 335
    • (2011) BMC Health Serv Res , vol.11 , pp. 335
    • Jansma, J.D.1    Wagner, C.2    Ten Kate, R.W.3
  • 77
    • 79952064620 scopus 로고    scopus 로고
    • To what extent are adverse events found in patient records reported by patients and healthcare professionals via complaints claims and incident reports?
    • Christiaans-Dingelhoff I, Smits M, Zwaan L, et al. To what extent are adverse events found in patient records reported by patients and healthcare professionals via complaints, claims and incident reports? BMC Health Serv Res 2011; 11: 49
    • (2011) BMC Health Serv Res , vol.11 , pp. 49
    • Christiaans-Dingelhoff, I.1    Smits, M.2    Zwaan, L.3
  • 78
    • 84855550612 scopus 로고    scopus 로고
    • Possible solutions for barriers in incident reporting by residents
    • Martowirono K, Jansma JD, van Luijk SJ, et al. Possible solutions for barriers in incident reporting by residents. J Eval Clin Pract 2012; 18: 76-81
    • (2012) J Eval Clin Pract , vol.18 , pp. 76-81
    • Martowirono, K.1    Jansma, J.D.2    Van Luijk, S.J.3
  • 79
    • 77951115384 scopus 로고    scopus 로고
    • Do specialty registrars change their attitudes intentions and behaviour towards reporting incidents following a patient safety course?
    • Jansma JD, Zwart DL, Leistikow IP, et al. Do specialty registrars change their attitudes, intentions and behaviour towards reporting incidents following a patient safety course? BMC Health Serv Res 2010; 10: 100
    • (2010) BMC Health Serv Res , vol.10 , pp. 100
    • Jansma, J.D.1    Zwart, D.L.2    Leistikow, I.P.3
  • 80
    • 81855164657 scopus 로고    scopus 로고
    • The nature and causes of unintended events reported at 10 internal medicine departments
    • Lubberding S, Zwaan L, Timmermans DR, et al. The nature and causes of unintended events reported at 10 internal medicine departments. J Patient Saf 2011; 7: 224-31
    • (2011) J Patient Saf , vol.7 , pp. 224-231
    • Lubberding, S.1    Zwaan, L.2    Timmermans, D.R.3
  • 81
    • 70449397223 scopus 로고    scopus 로고
    • The nature and causes of unintended events reported at ten emergency departments
    • Smits M, Groenewegen PP, Timmermans DR, et al. The nature and causes of unintended events reported at ten emergency departments. BMC Emerg Med 2009; 9: 16
    • (2009) BMC Emerg Med , vol.9 , pp. 16
    • Smits, M.1    Groenewegen, P.P.2    Timmermans, D.R.3
  • 82
    • 34250334712 scopus 로고    scopus 로고
    • The impact of duty hours on resident self reports of errors
    • Vidyarthi AR, Auerbach AD, Wachter RM, et al. The impact of duty hours on resident self reports of errors. J Gen Intern Med 2007; 22: 205-9
    • (2007) J Gen Intern Med , vol.22 , pp. 205-209
    • Vidyarthi, A.R.1    Auerbach, A.D.2    Wachter, R.M.3
  • 83
    • 21544449491 scopus 로고    scopus 로고
    • The end of the beginning: Patient safety five years after 'to err is human
    • Suppl Web Exclusives: W4-534-45
    • Wachter RM. The end of the beginning: patient safety five years after 'to err is human'. Health affairs 2004; Suppl Web Exclusives: W4-534-45
    • (2004) Health Affairs
    • Wachter, R.M.1
  • 85
    • 78650626755 scopus 로고    scopus 로고
    • Diagnostic error in a national incident reporting system in the UK
    • Sevdalis N, Jacklin R, Arora S, et al. Diagnostic error in a national incident reporting system in the UK. J Eval Clin Pract 2010; 16: 1276-81
    • (2010) J Eval Clin Pract , vol.16 , pp. 1276-1281
    • Sevdalis, N.1    Jacklin, R.2    Arora, S.3
  • 86
    • 72449187684 scopus 로고    scopus 로고
    • Improving patient safety incident reporting systems by focusing upon feedback-lessons from English and Welsh trusts
    • Wallace LM, Spurgeon P, Benn J, et al. Improving patient safety incident reporting systems by focusing upon feedback-lessons from English and Welsh trusts. Health Serv Manage Res 2009; 22: 129-35
    • (2009) Health Serv Manage Res , vol.22 , pp. 129-135
    • Wallace, L.M.1    Spurgeon, P.2    Benn, J.3
  • 87
    • 61849146295 scopus 로고    scopus 로고
    • Feedback from incident reporting: Information and action to improve patient safety
    • Benn J, Koutantji M, Wallace L, et al. Feedback from incident reporting: information and action to improve patient safety. Qual Saf Health Care 2009; 18: 11-21
    • (2009) Qual Saf Health Care , vol.18 , pp. 11-21
    • Benn, J.1    Koutantji, M.2    Wallace, L.3
  • 88
    • 33847344617 scopus 로고    scopus 로고
    • Hospital staff should use more than one method to detect adverse events and potential adverse events: Incident reporting, pharmacist surveillance and local real-time record review may all have a place
    • Olsen S, Neale G, Schwab K, et al. Hospital staff should use more than one method to detect adverse events and potential adverse events: incident reporting, pharmacist surveillance and local real-time record review May all have a place. Qual Saf Health Care 2007; 16: 40-4
    • (2007) Qual Saf Health Care , vol.16 , pp. 40-44
    • Olsen, S.1    Neale, G.2    Schwab, K.3
  • 89
    • 30444459783 scopus 로고    scopus 로고
    • Incident reporting in one UK accident and emergency department
    • Tighe CM, Woloshynowych M, Brown R, et al. Incident reporting in one UK accident and emergency department. Accid Emerg Nurs 2006; 14: 27-37
    • (2006) Accid Emerg Nurs , vol.14 , pp. 27-37
    • Tighe, C.M.1    Woloshynowych, M.2    Brown, R.3
  • 90
    • 0032942425 scopus 로고    scopus 로고
    • Reasons for not reporting adverse incidents: An empirical study
    • Vincent C, Stanhope N, Crowley-Murphy M. Reasons for not reporting adverse incidents: an empirical study. J Eval Clin Pract 1999; 5: 13-21
    • (1999) J Eval Clin Pract , vol.5 , pp. 13-21
    • Vincent, C.1    Stanhope, N.2    Crowley-Murphy, M.3
  • 92
    • 84879093352 scopus 로고    scopus 로고
    • Adverse events among ontario home care clients associated with emergency room visit or hospitalization: A retrospective cohort study
    • Doran DM, Hirdes JP, Blais R, et al. Adverse events among Ontario home care clients associated with emergency room visit or hospitalization: a retrospective cohort study. BMC Health Serv Res 2013; 13: 227
    • (2013) BMC Health Serv Res , vol.13 , pp. 227
    • Doran, D.M.1    Hirdes, J.P.2    Blais, R.3
  • 93
    • 80855151601 scopus 로고    scopus 로고
    • Reporting natural health product related adverse drug reactions is it the pharmacist's responsibility?
    • Walji R, Boon H, Barnes J, et al. Reporting natural health product related adverse drug reactions: is it the pharmacist's responsibility? Int J Pharm Pract 2011; 19: 383-91
    • (2011) Int J Pharm Pract , vol.19 , pp. 383-391
    • Walji, R.1    Boon, H.2    Barnes, J.3
  • 94
    • 67650567280 scopus 로고    scopus 로고
    • Adverse event reporting for herbal medicines: A result of market forces
    • Walji R, Boon H, Barnes J, et al. Adverse event reporting for herbal medicines: a result of market forces. Healthc Policy 2009; 4: 77-90
    • (2009) Healthc Policy , vol.4 , pp. 77-90
    • Walji, R.1    Boon, H.2    Barnes, J.3
  • 95
    • 79958239589 scopus 로고    scopus 로고
    • Identification of safety outcomes for Canadian home care clients: Evidence from the resident assessment instrument-home care reporting system concerning emergency room visits
    • Spec No Patient
    • Doran DM, Hirdes J, Poss J, et al. Identification of safety outcomes for Canadian home care clients: evidence from the resident assessment instrument-home care reporting system concerning emergency room visits. Healthc Q 2009; 12(Spec No Patient): 40-8
    • (2009) Healthc Q , vol.12 , pp. 40-48
    • Doran, D.M.1    Hirdes, J.2    Poss, J.3
  • 96
    • 33847646234 scopus 로고    scopus 로고
    • Factors influencing perioperative nurses' error reporting preferences
    • Espin S, Regehr G, Levinson W, et al. Factors influencing perioperative nurses' error reporting preferences. AORN J 2007; 85: 527-43
    • (2007) AORN J , vol.85 , pp. 527-543
    • Espin, S.1    Regehr, G.2    Levinson, W.3
  • 97
    • 8544225042 scopus 로고    scopus 로고
    • A system factors analysis of airway events from the intensive care unit safety reporting system (icusrs
    • Needham DM, Thompson DA, Holzmueller CG, et al. A system factors analysis of airway events from the Intensive Care Unit Safety Reporting System (ICUSRS). Crit Care Med 2004; 32: 2227-33
    • (2004) Crit Care Med , vol.32 , pp. 2227-2233
    • Needham, D.M.1    Thompson, D.A.2    Holzmueller, C.G.3
  • 98
    • 20044382998 scopus 로고    scopus 로고
    • Creating the web-based intensive care unit safety reporting system
    • Holzmueller CG, Pronovost PJ, Dickman F, et al. Creating the web-based intensive care unit safety reporting system. J Am Med Inform Assoc 2005; 12: 130-9
    • (2005) J Am Med Inform Assoc , vol.12 , pp. 130-139
    • Holzmueller, C.G.1    Pronovost, P.J.2    Dickman, F.3
  • 99
    • 69449107599 scopus 로고    scopus 로고
    • Enhancing safety reporting in adult ambulatory oncology with a clinician champion: A practice innovation
    • Weingart SN, Price J, Duncombe D, et al. Enhancing safety reporting in adult ambulatory oncology with a clinician champion: a practice innovation. J Nurs Care Qual 2009; 24: 203-10
    • (2009) J Nurs Care Qual , vol.24 , pp. 203-210
    • Weingart, S.N.1    Price, J.2    Duncombe, D.3
  • 100
    • 0033902022 scopus 로고    scopus 로고
    • Confidential clinician-reported surveillance of adverse events among medical inpatients
    • Weingart SN, Ship AN, Aronson MD. Confidential clinician-reported surveillance of adverse events among medical inpatients. J Gen Intern Med 2000; 15: 470-7
    • (2000) J Gen Intern Med , vol.15 , pp. 470-477
    • Weingart, S.N.1    Ship, A.N.2    Aronson, M.D.3
  • 101
    • 77958185459 scopus 로고    scopus 로고
    • Integrating incident data from five reporting systems to assess patient safety: Making sense of the elephant
    • Levtzion-Korach O, Frankel A, Alcalai H, et al. Integrating incident data from five reporting systems to assess patient safety: making sense of the elephant. Jt Comm J Qual Patient Saf 2010; 36: 402-10
    • (2010) Jt Comm J Qual Patient Saf , vol.36 , pp. 402-410
    • Levtzion-Korach, O.1    Frankel, A.2    Alcalai, H.3
  • 102
    • 41149178154 scopus 로고    scopus 로고
    • Testing the technology acceptance model for evaluating healthcare professionals' intention to use an adverse event reporting system
    • Wu JH, Shen WS, Lin LM, et al. Testing the technology acceptance model for evaluating healthcare professionals' intention to use an adverse event reporting system. Int J Qual Health Care 2008; 20: 123-9
    • (2008) Int J Qual Health Care , vol.20 , pp. 123-129
    • Wu, J.H.1    Shen, W.S.2    Lin, L.M.3
  • 103
    • 78649502684 scopus 로고    scopus 로고
    • Secondary use of electronic health record data: Spontaneous triggered adverse drug event reporting
    • Linder JA, Haas JS, Iyer A, et al. Secondary use of electronic health record data: spontaneous triggered adverse drug event reporting. Pharmacoepidemiol Drug Saf 2010; 19: 1211-15
    • (2010) Pharmacoepidemiol Drug Saf , vol.19 , pp. 1211-1215
    • Linder, J.A.1    Haas, J.S.2    Iyer, A.3
  • 104
    • 68349125713 scopus 로고    scopus 로고
    • Evaluation of the contributions of an electronic web-based reporting system: Enabling action
    • Levtzion-Korach O, Alcalai H, Orav EJ, et al. Evaluation of the contributions of an electronic web-based reporting system: enabling action. J Patient Saf 2009; 5: 9-15
    • (2009) J Patient Saf , vol.5 , pp. 9-15
    • Levtzion-Korach, O.1    Alcalai, H.2    Orav, E.J.3
  • 105
    • 31544482442 scopus 로고    scopus 로고
    • Results of a survey on medical error reporting systems in Korean hospitals
    • Kim J, Bates DW. Results of a survey on medical error reporting systems in Korean hospitals. Int J Med Inform 2006; 75: 148-55
    • (2006) Int J Med Inform , vol.75 , pp. 148-155
    • Kim, J.1    Bates, D.W.2
  • 106
    • 0029384423 scopus 로고
    • The incident reporting system does not detect adverse drug events: A problem for quality improvement
    • Cullen DJ, Bates DW, Small SD, et al. The incident reporting system does not detect adverse drug events: a problem for quality improvement. Jt Comm J Qual Improv 1995; 21: 541-8
    • (1995) Jt Comm J Qual Improv , vol.21 , pp. 541-548
    • Cullen, D.J.1    Bates, D.W.2    Small, S.D.3
  • 107
    • 0027369391 scopus 로고
    • Physician reporting compared with medical-record review to identify adverse medical events
    • O'Neil AC, Petersen LA, Cook EF, et al. Physician reporting compared with medical-record review to identify adverse medical events. Ann Intern Med 1993; 119: 370-6
    • (1993) Ann Intern Med , vol.119 , pp. 370-376
    • O'neil, A.C.1    Petersen, L.A.2    Cook, E.F.3
  • 109
    • 84894315175 scopus 로고    scopus 로고
    • Comparison of intensive care unit medication errors reported to the united states' medmarx and the united kingdom's national reporting and learning system: A cross-sectional study
    • Wahr JA, Shore AD, Harris LH, et al. Comparison of intensive care unit medication errors reported to the United States' MedMarx and the United Kingdom's National Reporting and Learning System: a cross-sectional study. Am J Med Qual 2014; 29: 61-9
    • (2014) Am J Med Qual , vol.29 , pp. 61-69
    • Wahr, J.A.1    Shore, A.D.2    Harris, L.H.3
  • 110
    • 79958048321 scopus 로고    scopus 로고
    • A public health approach to patient safety reporting systems is urgently needed
    • Noble DJ, Panesar SS, Pronovost PJ. A public health approach to patient safety reporting systems is urgently needed. J Patient Saf 2011; 7: 109-12
    • (2011) J Patient Saf , vol.7 , pp. 109-112
    • Noble, D.J.1    Panesar, S.S.2    Pronovost, P.J.3
  • 111
    • 79958064110 scopus 로고    scopus 로고
    • Patient-assisted incident reporting: Including the patient in patient safety
    • Millman EA, Pronovost PJ, Makary MA, et al. Patient-assisted incident reporting: including the patient in patient safety. J Patient Saf 2011; 7: 106-8
    • (2011) J Patient Saf , vol.7 , pp. 106-108
    • Millman, E.A.1    Pronovost, P.J.2    Makary, M.A.3
  • 112
    • 79952591723 scopus 로고    scopus 로고
    • Cardiac surgery errors: Results from the uk national reporting and learning system
    • Martinez EA, Shore A, Colantuoni E, et al. Cardiac surgery errors: results from the UK National Reporting and Learning System. Int J Qual Health Care 2011; 23: 151-8
    • (2011) Int J Qual Health Care , vol.23 , pp. 151-158
    • Martinez, E.A.1    Shore, A.2    Colantuoni, E.3
  • 113
    • 77956439714 scopus 로고    scopus 로고
    • New legal protections for reporting patient errors under the patient safety and quality improvement act: A review of the medical literature and analysis
    • Howard J, Levy F, Mareiniss DP, et al. New legal protections for reporting patient errors under the Patient Safety and Quality Improvement Act: a review of the medical literature and analysis. J Patient Saf 2010; 6: 147-52
    • (2010) J Patient Saf , vol.6 , pp. 147-152
    • Howard, J.1    Levy, F.2    Mareiniss, D.P.3
  • 114
    • 79953034930 scopus 로고    scopus 로고
    • Mandatory public reporting: Build it and who will come?
    • Bell S, Benneyan J, Best A, et al. Mandatory public reporting: build it and who will come? Stud Health Technol Inform 2011; 164: 346-52
    • (2011) Stud Health Technol Inform , vol.164 , pp. 346-352
    • Bell, S.1    Benneyan, J.2    Best, A.3
  • 115
    • 55849126054 scopus 로고    scopus 로고
    • The squire (standards for quality improvement reporting excellence) guidelines for quality improvement reporting: Explanation and elaboration
    • Ogrinc G, Mooney SE, Estrada C, et al. The SQUIRE (Standards for QUality Improvement Reporting Excellence) guidelines for quality improvement reporting: explanation and elaboration. Qual Saf Health Care 2008; 17(Suppl 1): i13-32
    • (2008) Qual Saf Health Care , vol.17 , pp. i13-32
    • Ogrinc, G.1    Mooney, S.E.2    Estrada, C.3
  • 116
    • 78249248665 scopus 로고    scopus 로고
    • The harm susceptibility model: A method to prioritise risks identified in patient safety reporting systems
    • Pham JC, Colantuoni E, Dominici F, et al. The harm susceptibility model: a method to prioritise risks identified in patient safety reporting systems. Qual Saf Health Care 2010; 19: 440-5
    • (2010) Qual Saf Health Care , vol.19 , pp. 440-445
    • Pham, J.C.1    Colantuoni, E.2    Dominici, F.3
  • 117
    • 85011612245 scopus 로고    scopus 로고
    • NHS England Patient Safety Never Events
    • NHS England Patient Safety Never Events. Secondary NHS England Patient Safety Never Events. https://http://www. england.nhs.uk/patientsafety/never-events/
    • Secondary NHS England Patient Safety Never Events
  • 118
    • 33846289616 scopus 로고    scopus 로고
    • Incident reporting and patient safety
    • Vincent C. Incident reporting and patient safety. BMJ 2007; 334: 51
    • (2007) BMJ , vol.334 , pp. 51
    • Vincent, C.1
  • 119
    • 84955274720 scopus 로고    scopus 로고
    • The problem with incident reporting
    • Macrae C. The problem with incident reporting. BMJ Qual Saf 2015; doi: 10.1136/bmjqs-2015-004732
    • (2015) BMJ Qual Saf
    • Macrae, C.1
  • 120
    • 61849101459 scopus 로고    scopus 로고
    • Trends in healthcare incident reporting and relationship to safety and quality data in acute hospitals: Results from the national reporting and learning system
    • Hutchinson A, Young TA, Cooper KL, et al. Trends in healthcare incident reporting and relationship to safety and quality data in acute hospitals: results from The National Reporting and Learning System. Qual Saf Health Care 2009; 18: 5-10
    • (2009) Qual Saf Health Care , vol.18 , pp. 5-10
    • Hutchinson, A.1    Young, T.A.2    Cooper, K.L.3
  • 121
    • 4043154175 scopus 로고    scopus 로고
    • Analysis of clinical incidents: A window on the system not a search for root causes
    • Vincent CA. Analysis of clinical incidents: a window on the system not a search for root causes. Qual Saf Health Care 2004; 13: 242-3
    • (2004) Qual Saf Health Care , vol.13 , pp. 242-243
    • Vincent, C.A.1
  • 122
    • 84929074145 scopus 로고    scopus 로고
    • Npitxt, a 21st-century reporting system: Engaging residents in a lean-inspired process
    • Raja PV, Davis MC, Bales A, et al. NPITxt, a 21st-Century Reporting System: Engaging Residents in a Lean-Inspired Process. Am J Med Qual 2015; 30: 255-62
    • (2015) Am J Med Qual , vol.30 , pp. 255-262
    • Raja, P.V.1    Davis, M.C.2    Bales, A.3
  • 123
    • 84873337978 scopus 로고    scopus 로고
    • Training health care professionals in root cause analysis: A cross-sectional study of post-training experiences, benefits and attitudes
    • Bowie P, Skinner J, de Wet C. Training health care professionals in root cause analysis: a cross-sectional study of post-training experiences, benefits and attitudes. BMC Health Serv Res 2013; 13: 50
    • (2013) BMC Health Serv Res , vol.13 , pp. 50
    • Bowie, P.1    Skinner, J.2    De Wet, C.3
  • 124
    • 84870490307 scopus 로고    scopus 로고
    • National and local medication error reporting systems: A survey of practices in 16 countries
    • Holmström AR, Airaksinen M, Weiss M, et al. National and local medication error reporting systems: a survey of practices in 16 countries. J Patient Saf 2012; 8: 165-76
    • (2012) J Patient Saf , vol.8 , pp. 165-176
    • Holmström, A.R.1    Airaksinen, M.2    Weiss, M.3
  • 126
    • 70349916091 scopus 로고    scopus 로고
    • Voluntary and mandatory surveillance for methicillin-resistant staphylococcus aureus (mrsa) and methicillin-susceptible s aureus (mssa) bacteraemia in england
    • Pearson A, Chronias A, Murray M. Voluntary and mandatory surveillance for methicillin-resistant Staphylococcus aureus (MRSA) and methicillin-susceptible S. aureus (MSSA) bacteraemia in England. J Antimicrob Chemother 2009; 64 (Suppl 1): i11-17
    • (2009) J Antimicrob Chemother , vol.64 , pp. i11-17
    • Pearson, A.1    Chronias, A.2    Murray, M.3
  • 127
    • 33947634368 scopus 로고    scopus 로고
    • Lessons learned from the evolution of mandatory adverse event reporting systems
    • In: Henriksen K Battles JB Marks ES et al eds Implementation Issues). Rockville MD
    • Flink E, Chevalier CL, Ruperto A, et al. Lessons Learned from the Evolution of Mandatory Adverse Event Reporting Systems. In: Henriksen K, Battles JB, Marks ES, et al, eds. Advances in patient safety: from research to implementation (Volume 3: Implementation Issues). Rockville, MD, 2005: http://www.ncbi.nlm.nih.gov/books/NBK20547/
    • (2005) Advances in Patient Safety: From Research to Implementation , vol.3
    • Flink, E.1    Chevalier, C.L.2    Ruperto, A.3
  • 128
    • 33244493122 scopus 로고    scopus 로고
    • Attitudes and barriers to incident reporting: A collaborative hospital study
    • Evans SM, Berry JG, Smith BJ, et al. Attitudes and barriers to incident reporting: a collaborative hospital study. Qual Saf Health Care 2006; 15: 39-43
    • (2006) Qual Saf Health Care , vol.15 , pp. 39-43
    • Evans, S.M.1    Berry, J.G.2    Smith, B.J.3
  • 129
    • 84922245028 scopus 로고    scopus 로고
    • Is having quality as an item on the executive board agenda associated with the implementation of quality management systems in European hospitals: A quantitative analysis
    • Botje D, Klazinga NS, Suñol R, et al. Is having quality as an item on the executive board agenda associated with the implementation of quality management systems in European hospitals: a quantitative analysis. Int J Qual Health Care 2014; 26(Suppl 1): 92-9
    • (2014) Int J Qual Health Care , vol.26 , pp. 92-99
    • Botje, D.1    Klazinga, N.S.2    Suñol, R.3
  • 130
    • 46149118989 scopus 로고    scopus 로고
    • The Darzi vision: Quality, engagement, and professionalism
    • Horton R. The Darzi vision: quality, engagement, and professionalism. Lancet 2008; 372: 3-4
    • (2008) Lancet , vol.372 , pp. 3-4
    • Horton, R.1
  • 131
    • 77954699134 scopus 로고    scopus 로고
    • Responsibility for quality improvement and patient safety: Hospital board and medical staff leadership challenges
    • Goeschel CA, Wachter RM, Pronovost PJ. Responsibility for quality improvement and patient safety: hospital board and medical staff leadership challenges. Chest 2010; 138: 171-8
    • (2010) Chest , vol.138 , pp. 171-178
    • Goeschel, C.A.1    Wachter, R.M.2    Pronovost, P.J.3


* 이 정보는 Elsevier사의 SCOPUS DB에서 KISTI가 분석하여 추출한 것입니다.