Hosp Health Netw. 2001 Apr;75(4):33-4.
The meat and potatoes of error reduction is in the root cause analysis of mistakes and near-misses, and the identification of new, safer ways to carry out tasks. This is also the most technical part of patient safety. But hospital leaders find that their staffs can learn from mistakes using home-grown expertise and wisdom, and that it works best if everyone is willing to open up their daily work lives to some well-intentioned scrutiny.
减少错误的关键在于对错误和险些发生的失误进行根本原因分析，并找出执行任务的新的、更安全的方法。这也是患者安全中最具技术性的部分。但医院领导发现，他们的员工可以利用自身的专业知识和智慧从错误中学习，而且如果每个人都愿意让自己的日常工作接受一些善意的审视，效果会最佳。
