20世纪90年代末，全球医院界开始了医疗不良事件上报管理的探索和实践，旨在及时发现医疗安全缺陷、规避医疗风险、提高患者安全水平。2007年以来，北京协和医院学习借鉴国际做法，结合医院实际，开展了这项管理工作，分3个阶段推进，至今历时 7年，探索总结出不同管理层面的具体工作办法和经验，取得了良好成效，形成了从指责文化到系统改进的医疗安全文化，医疗安全管理可持续发展。%Since the end of 1990s,the global hospital industry has begun to explore and practice the reporting man-agement of medical adverse events in order to timely discover medical safety defects,avoid medical risks and improve pa-tient safety. And since 2006,Peking Union Medical College Hospital has practically carried out the management by refer-ring to international performance. After nine years,good results,including detailed working methods and relevant experi-ence at different levels of management have been explored and achieved while sustainable development in medical safety culture ranging from rebuking to systematic improvement has been obtained.
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