JCI的基本理念之一是基于促进医疗质量与患者安全的持续性改进的原则,其中强调对影响患者安全的意外不良事件进行根本原因分析,使每个科室成员都能从不良事件中吸取经验,采取预防对策,使风险防御能力得以持续提升,以实现保证患者安全和提升医疗质量为核心的医院管理目标.本文通过探索建立不良事件报告系统,提高个人、科室防范不良事件的能力,提升医疗质量和安全.同时通过推广、扩展至科间、院际的交流,找到危害的根源,累积经验,分析趋势,实现经验分享与交流,更大范围实现患者安全的管理目标.%One of the fundamental concepts of JCI is to promote medical quality and patients' safety. It stresses the analysis of the basic causes of adverse effect. Through JCI, all staff could get experience from the adverse effect. Thus, we can take preventive methods to promote the ability of risk defense to realize the medical-quality-orien-ted target of medical management. The article introduced the application of adverse effect reporting system in one hospital. After practice, the hospital raised the personal and department ability of preventing adverse effect, set up the medical quality and safety. Meanwhile, through improving the communication among the departments and hos-pitals, the root of hazards was found, experience was accumulated, the trend was analyzed, and experience sharing was realized. All these aspects widely achieved the management target of patient' s safety.
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