Sutcliffe K M
University of Michigan Business School, in Ann Arbor, MI, USA.
Ambul Outreach. 2000 Spring:30-4.
Traditional analyses of adverse medical events and errors have focused on individuals. The search for a cause typically has stopped at the person closest to the accident who, it is determined after the fact, could have acted differently in a way that would have led to a different outcome. Traditional approaches have focused on people as unreliable components. But the new look at error has shifted its focus from individuals to the systems in which these individuals are situated. I want to add to this discussion by reporting on an analysis of non-medical organizations called "high reliability organizations" (or HROs) that incur similar temptations to blame individuals rather than systems, but have been successful in focusing attention on systems. The point of this discussion is to suggest that the ways in which HROs do this are instructive for medical organizations whose goal is fewer adverse events.
传统上对不良医疗事件和差错的分析都聚焦于个体。对原因的探寻通常止于最接近事故的人，事后认定此人原本可以采取不同的行动从而导致不同的结果。传统方法将人视为不可靠的组成部分。但对差错的新视角已将关注点从个体转移到个体所处的系统。我想通过汇报一项对非医疗组织“高可靠性组织”（简称HROs）的分析来加入这场讨论，这些组织也面临类似的倾向，即指责个体而非系统，但它们成功地将注意力集中在了系统上。这场讨论的要点在于表明，高可靠性组织做到这一点的方式对那些目标是减少不良事件的医疗组织具有指导意义。
