Abstract：
BACKGROUND: The topic of patient safety has been a subject of much discussion since the end of the last millennium. Ensuring patient safety is a central challenge in health care. An important tool to raise awareness for and learn from adverse events and thus promote patient safety are error-reporting and learning systems (Critical Incident Reporting System = CIRS).
METHODS: More than 17 years after its establishment, the CIRS \"jeder-fehler-zaehlt.de\" (JFZ) for German primary care has undergone a revision in terms of content and technology. The revised web-based system can be used for reporting as well as for classifying and analyzing incident reports. During this process, a descriptive analysis of the current report inventory was carried out, with a focus on serious medication errors. This included all 781 valid incident reports received between September 2004 and December 2021.
RESULTS: In 576 of the 781 reports (73.8%), the GP practice was directly involved in the critical incident. Among error types, process errors predominated (79.8% of the classifications, 99.1% of the reports) compared with knowledge and skills errors (20.2% of the classifications, 39.7% of the reports). Communication errors (63.0%) were the most common contributing factor to critical incidents, followed by flaws in tasks and measures (39.7%). Serious and permanent patient harm was rarely reported (8.3% of the reports), whereas temporary patient harm was more common (40.3% of the reports). Incident reports about medication errors with at least serious patient harm included, in particular, substances that affected blood clotting, corticosteroids, and opiates.
CONCLUSIONS: Our results complement the rates that are reported internationally for error types, patient harm, and contributing factors. Serious but preventable adverse events, so-called never events, are frequently associated with the medication process in both JFZ reports and the literature.
CONCLUSIONS: Critical incident reporting systems cannot provide accurate information about the frequency of errors in health care, but they can offer important insights into, for example, serious medication errors. Therefore, they offer both employees and healthcare institutions an opportunity for individual and institutional learning.
METHODS: More than 17 years after its establishment, the CIRS \"jeder-fehler-zaehlt.de\" (JFZ) for German primary care has undergone a revision in terms of content and technology. The revised web-based system can be used for reporting as well as for classifying and analyzing incident reports. During this process, a descriptive analysis of the current report inventory was carried out, with a focus on serious medication errors. This included all 781 valid incident reports received between September 2004 and December 2021.
RESULTS: In 576 of the 781 reports (73.8%), the GP practice was directly involved in the critical incident. Among error types, process errors predominated (79.8% of the classifications, 99.1% of the reports) compared with knowledge and skills errors (20.2% of the classifications, 39.7% of the reports). Communication errors (63.0%) were the most common contributing factor to critical incidents, followed by flaws in tasks and measures (39.7%). Serious and permanent patient harm was rarely reported (8.3% of the reports), whereas temporary patient harm was more common (40.3% of the reports). Incident reports about medication errors with at least serious patient harm included, in particular, substances that affected blood clotting, corticosteroids, and opiates.
CONCLUSIONS: Our results complement the rates that are reported internationally for error types, patient harm, and contributing factors. Serious but preventable adverse events, so-called never events, are frequently associated with the medication process in both JFZ reports and the literature.
CONCLUSIONS: Critical incident reporting systems cannot provide accurate information about the frequency of errors in health care, but they can offer important insights into, for example, serious medication errors. Therefore, they offer both employees and healthcare institutions an opportunity for individual and institutional learning.
摘要：
背景：自上世纪末期以来，患者安全的话题一直是人们讨论的话题。确保患者安全是医疗保健的核心挑战。提高对不良事件的认识并从中学习，从而促进患者安全的重要工具是错误报告和学习系统（关键事件报告系统=CIRS）。
方法：成立17年多后，CIRS\“jeder-fehler-zaehlt。德国初级保健的de\“(JFZ)在内容和技术方面进行了修订。修订后的基于Web的系统可用于报告以及对事件报告进行分类和分析。在这个过程中,对当前报告清单进行了描述性分析，重点关注严重的用药错误。这包括2004年9月至2021年12月期间收到的所有781份有效事件报告。
结果：在781份报告中的576份（73.8%），全科医生的实践直接参与了危重事件.在错误类型中，过程错误占主导地位(79.8%的分类，99.1％的报告）与知识和技能错误（20.2％的分类，39.7%的报告)。沟通错误(63.0%)是导致重大事件的最常见因素，其次是任务和措施的缺陷(39.7%)。很少报告严重和永久性的患者伤害（占报告的8.3％）。而暂时性患者伤害更为常见(占报告的40.3%).包括至少对患者造成严重伤害的用药错误的事件报告，特别是,影响血液凝固的物质，皮质类固醇,和鸦片。
结论：我们的结果补充了国际上报告的错误类型的比率，病人的伤害,和促成因素。严重但可预防的不良事件，所谓的从不事件，在JFZ报告和文献中都经常与药物治疗过程相关。
结论：重大事件报告系统无法提供有关医疗保健错误发生频率的准确信息，但是他们可以提供重要的见解，例如,严重的用药错误因此,他们为员工和医疗机构提供了个人和机构学习的机会。
方法：成立17年多后，CIRS\“jeder-fehler-zaehlt。德国初级保健的de\“(JFZ)在内容和技术方面进行了修订。修订后的基于Web的系统可用于报告以及对事件报告进行分类和分析。在这个过程中,对当前报告清单进行了描述性分析，重点关注严重的用药错误。这包括2004年9月至2021年12月期间收到的所有781份有效事件报告。
结果：在781份报告中的576份（73.8%），全科医生的实践直接参与了危重事件.在错误类型中，过程错误占主导地位(79.8%的分类，99.1％的报告）与知识和技能错误（20.2％的分类，39.7%的报告)。沟通错误(63.0%)是导致重大事件的最常见因素，其次是任务和措施的缺陷(39.7%)。很少报告严重和永久性的患者伤害（占报告的8.3％）。而暂时性患者伤害更为常见(占报告的40.3%).包括至少对患者造成严重伤害的用药错误的事件报告，特别是,影响血液凝固的物质，皮质类固醇,和鸦片。
结论：我们的结果补充了国际上报告的错误类型的比率，病人的伤害,和促成因素。严重但可预防的不良事件，所谓的从不事件，在JFZ报告和文献中都经常与药物治疗过程相关。
结论：重大事件报告系统无法提供有关医疗保健错误发生频率的准确信息，但是他们可以提供重要的见解，例如,严重的用药错误因此,他们为员工和医疗机构提供了个人和机构学习的机会。
