Taiwan Patient safety Reporting system

The issue of “Patient safety” has brought great attention since the release of the report: ”To Err is Human” from the Institute of Medicine (IOM) in U.S.A. in 1999. After that, many countries started to establish incidents reporting systems, which is considered one of the fundamental and important measures, for data collection in order to enhance patient safety. The Taiwan Patient-safety Reporting system (TPR) was introduced in December 2003 through the Ministry of Health and Welfare (MOHW) authorizing the Joint Commission of Taiwan (JCT) to undertake the project.
In addition, the abbreviation “TPR”, used in the clinical settings, stands for temperature, pulse and respiration, which are key vital signs for a patient’s life. The reporting system has been named “TPR” because it also emphasizes that “reporting” is the important thing to do as patient’s care. Five principles are followed to encourage reporting, including anonymity, voluntariness, non-punitive, confidentiality and mutual learning.

In the TPR system, 13 different categories are offered to choose reporting an event, including falls, medication errors, violence/suicide, tubing related incidents, security, accident, surgery related incidents, anesthesia related incidents, blood transfusion associated incidents, unexpected cardiac arrest, medical practice related, laboratory related incidents, others. Besides, data can be simply submitted via a webpage uploading, TPR software installation or data mapping way.

There were 14,548 facilities (including clinics) joining TPR in Taiwan and 790,660 events were reported totally between 2005 and 2020. The number of participating organizations and reporting events are increasing annually.
Medication errors were the most frequent event reported to TPR in 2020 (25,528 reported), followed by falls (20,228), and tubing related incidents (10,907) according to figure 1. In addition, there were 6,907 violence/suicide incidents and 5,505 laboratory related events in the same year. The less reported event type was the Anesthesia events, 102 in total in 2020.

Figure 1. The types of TPR Reporting Events in 2020

Figure 2 illustrates the outcomes of reporting events related to patients in 2020. The majority of events caused patients no harm was 36.1% (28,708 reported), followed by events resulting in near miss (27.8%, 22,133). In addition, 16,971 (21.3%) events were reported minor harm to patients and 8,517 (10.7%) happened events caused moderate harm to patients. There were 1,191 (1.5%) events contributing to major harm for patients; meanwhile, 564 incidents led death to patients.

Figure 2. Outcomes of events on Patients in 2020