Dean B
Clinical Services, Academic Pharmacy Unit, Hammersmith Hospitals NHS Trust, Du Cane Road, London W12 0HS, UK.
Qual Saf Health Care. 2002 Sep;11(3):258-60. doi: 10.1136/qhc.11.3.258.
The importance of learning from medical error has recently received increasing emphasis. This paper focuses on prescribing errors and argues that, while learning from prescribing errors is a laudable goal, there are currently barriers that can prevent this occurring. Learning from errors can take place on an individual level, at a team level, and across an organisation. Barriers to learning from prescribing errors include the non-discovery of many prescribing errors, lack of feedback to the prescriber when errors are discovered by other healthcare professionals, and a culture that does not encourage reflection on errors together with why they occurred and how they can be prevented. Changes are needed in both systems and culture to provide an environment in which lessons can be learnt from errors and put into practice.
从医疗差错中吸取教训的重要性最近受到了越来越多的重视。本文聚焦于处方差错，并指出，虽然从处方差错中吸取教训是一个值得称赞的目标，但目前存在一些障碍可能会阻碍这一目标的实现。从差错中吸取教训可以在个人层面、团队层面以及整个组织范围内进行。从处方差错中吸取教训的障碍包括许多处方差错未被发现、当其他医疗专业人员发现差错时未向开处方者提供反馈，以及一种不鼓励对差错及其发生原因和预防方法进行反思的文化。系统和文化都需要做出改变，以营造一个能够从差错中吸取教训并将其付诸实践的环境。
