Rall M, Schaedle B, Zieger J, Naef W, Weinlich M
Tübinger Patienten-Sicherheits- und Simulationszentrum (TüPASS), Klinik für Anästhesiologie und Intensivmedizin, Universitätsklinikum Tübingen, Germany.
Unfallchirurg. 2002 Nov;105(11):1033-42. doi: 10.1007/s00113-002-0523-3.
Patient safety is determined by the performance safety of the medical team. Errors in medicine are amongst the leading causes of death of hospitalized patients. These numbers call for action. Backgrounds, methods and new forms of training are introduced in this article.
Concepts from safety research are transformed to the field of emergency medical treatment. Strategies from realistic patient simulator training sessions and innovative training concepts are discussed.
The reasons for the high numbers of errors in medicine are not due to a lack of medical knowledge, but due to human factors and organisational circumstances. A first step towards an improved patient safety is to accept this. We always need to be prepared that errors will occur. A next step would be to separate "error" from guilt (culture of blame) allowing for a real analysis of accidents and establishment of meaningful incident reporting systems. Concepts with a good success record from aviation like "crew resource management" (CRM) training have been adapted my medicine and are ready to use. These concepts require theoretical education as well as practical training. Innovative team training sessions using realistic patient simulator systems with video taping (for self reflexion) and interactive debriefing following the sessions are very promising.
As the need to reduce error rates in medicine is very high and the reasons, methods and training concepts are known, we are urged to implement these new training concepts widely and consequently. To err is human - not to counteract it is not.
患者安全取决于医疗团队的工作安全。医疗失误是住院患者死亡的主要原因之一。这些数据呼吁采取行动。本文介绍了背景、方法和新的培训形式。
将安全研究中的概念应用于急诊医学领域。讨论了来自真实患者模拟器培训课程的策略和创新培训概念。
医疗中出现大量失误的原因并非缺乏医学知识,而是人为因素和组织环境。提高患者安全的第一步是承认这一点。我们必须时刻做好准备,接受失误会发生的事实。下一步是将“失误”与罪责(责备文化)区分开来,以便对事故进行真正的分析,并建立有意义的事件报告系统。航空领域中有着良好成功记录的概念,如“机组资源管理”(CRM)培训,已被医学领域采用并可供使用。这些概念需要理论教育和实践培训。使用带有录像功能(用于自我反思)的真实患者模拟器系统进行创新团队培训课程,并在课程结束后进行互动式汇报,前景十分广阔。
由于降低医疗失误率的需求非常迫切,且原因、方法和培训概念都已明确,我们被敦促广泛且果断地实施这些新的培训概念。人孰能无过——但不采取措施应对则不可原谅。