Cohen M R, Senders J, Davis N M
Institute for Safe Medication Practices, Huntingdon Valley, PA 19006.
Hosp Pharm. 1994 Apr;29(4):319-30.
It is time that hospitals realize that human error is inevitable and must be anticipated. A technique developed in the aerospace industry and known as "failure mode and effects analysis" involves identifying mistakes that will happen before they happen, and determining whether the consequences of those mistakes would be tolerable or intolerable. This article shows how this practice can be adapted to a hospital environment by using a continuous quality improvement approach. Examples show how actual fatal errors can be prevented.
医院是时候认识到人为错误不可避免且必须加以预见了。航空航天工业开发的一种名为“失效模式与效应分析”的技术，包括在错误发生之前识别可能出现的失误，并确定这些失误的后果是可容忍还是不可容忍的。本文展示了如何通过采用持续质量改进方法，使这种做法适用于医院环境。实例说明了如何预防实际发生的致命错误。
