醫學中心評鑑的醫療品質暨病人安全

2023年醫院評鑑暨教學醫院評鑑於臺北區與北區有14家醫院參加醫學中心評鑑，分析統計醫學中心任務指標任務三卓越的醫療品質與病人安全的4個項次9條基準32款評分說明的執行結果，大部分皆能達到評分說明的要求，有少數醫院可能未在任務指標審查資料表說明，或缺少部分內容，但整體都能呈現出卓越的醫療品質與病人安全成果。不過醫院投入醫品病安金額占醫院總收入的佔比差異很大，臺灣病人安全通報系統(TPR)件數與其他全院性通報系統之通報件數，每家醫院呈報的數字差異也很大，可能與醫院規定的病人安全通報類別與流程不同導致，將來也許需要清楚的界定。2023年醫學中心評鑑結果，各醫院評鑑成績持續進步，差異逐漸縮小，14家申請醫學中心評鑑之13家醫院，成績均達醫學中心評鑑標準，顯示參加醫學中心評鑑的醫院，都具有一定的水準，尤其醫療品質與病人安全皆能按照任務三的基準執行，得到良好的表現。建議以後，除落實執行衛福部規定的醫療品質及病人安全工作目標外，病人安全通報(TPR)後，進行根本原因分析(RCA)應確實按照衛福部「病人安全事件根本原因分析作業程序」參考指引執行，找出造成重大病安事件或流程執行失效根本原因，提出具體改善措施，以防止再次發生危害事件的機會。  In 2023, 14 hospitals in Taipei and in the North District of Taiwan applied for Hospital and Teaching Hospital Accreditation. An analysis and compilation of the implementation results of the medical center’s mission indicators for Mission Three, “Excellent Medical Quality and Patient Safety,” revealed 4 categories, 9 standards, and 32 scoring instruction items. The majority of the implementation results met the requirements of the scoring instructions. A few hospitals may not have provided explanations in the mission indicator review information sheet or may have been missing some content, but overall, they demonstrated excellent medical quality and patient safety results. Nevertheless, the proportion of each hospital’s investment in medical quality and patient safety relative to its total revenue varied greatly. The number of reports submitted to the Taiwan patient safety reporting system and other hospital-wide reporting systems also differed greatly among hospitals, possibly due to differences in the patient safety notification categories and procedures prescribed by each institution. These aspects may require clearer definition in the future. The medical center accreditation results demonstrated continued improvement in each hospital’s scores, with the differences gradually narrowing. In total, 13 out of the 14 hospitals that applied for medical center accreditation achieved scores that met the accreditation standards, demonstrating a certain level of excellence, particularly in implementing Mission Three’s standards for medical quality and patient safety and achieving good performance. In the future, hospitals should not only implement the medical quality and patient safety goals stipulated by the Ministry of Health and Welfare but also conduct root cause analyses following Taiwan patient safety reporting system in accordance with the Ministry of Health and Welfare’s ""Root Cause Analyses Operational Procedures for Patient Safety Incidents."" Hospitals should identify the root causes of major health and safety incidents or process execution failures and propose specific improvement measures to prevent the recurrence of hazardous incidents.