摘要
首先综合分析了现今中国社会对医疗缺陷的固有认识,继而从人本因素和认知理论的角度,讨论了操作性失误和决策性失误的概念、潜在缺陷及缺陷发生的机理、缺陷发生的系统因素以及如何设计一个安全的系统以防止缺陷的发生。提出医护服务系统安全设计应注意的8个方面①高度重视医疗安全工作;②及时发现缺陷;③减少对记忆的依赖;④使用约束和强制功能;⑤避免过分依赖人的警惕性;⑥简化和标准化关键程序;⑦设计系统的缓冲和恢复功能;⑧建立非惩罚性的报告制度。
The paper first offers a comprehensive analysis of the existing social understanding of medical errors and then discusses from the angles of humanistic factors and cognitive theories the concepts of operational errors, decisional errors and latent errors, error occurrence mechanisms, system related error occurrence, and ways of designing a safety system that can prevent error occurrence. The paper sets forth 8 aspects that ought to be stressed in the safety design of a patient care system: ①attaching great importance to medical safety; ②discovering errors in a timely manner; ③reducing reliance on memories; ④using force and restraint; ⑤avoiding over reliance on human vigilance; ⑥simplifying and standardizing key procedures; ⑦designing system buffer and recovery functions; ⑧establishing non punitive reporting systems.
出处
《中华医院管理杂志》
2004年第11期641-644,共4页
Chinese Journal of Hospital Administration
