Ottewill Melanie
Royal Sussex County Hospital.
Br J Nurs. 2003;12(15):919-24. doi: 10.12968/bjon.2003.12.15.11419.
There is a large body of research to suggest that serious errors are widespread throughout medicine. The traditional response to these adverse events has been to adopt a 'person approach' - blaming the individual seen as 'responsible'. The culture of medicine is highly complicit in this response. Such an approach results in enormous personal costs to the individuals concerned and does little to address the root causes of errors and thus prevent their recurrence. Other industries, such as aviation, where safety is a paramount concern and which have similar structures to the medical profession, have, over the past decade or so, adopted a 'systems' approach to error, recognizing that human error is ubiquitous and inevitable and that systems need to be developed with this in mind. This approach has been highly successful, but has necessitated, first and foremost, a cultural shift. It is in the best interests of patients, and medical professionals alike, that such a shift is embraced in the NHS.
有大量研究表明，严重错误在整个医疗行业中普遍存在。对这些不良事件的传统应对方式是采取“针对个人的方法”——指责被视为“有责任”的个人。医学界的文化在这种应对方式中难辞其咎。这种方法给相关个人带来了巨大的个人代价，而且几乎无助于解决错误的根本原因，从而防止其再次发生。其他行业，如航空业，安全是首要关注点，且其结构与医疗行业类似，在过去十年左右的时间里，采用了一种“系统”方法来处理错误，认识到人为错误无处不在且不可避免，系统的开发需要考虑到这一点。这种方法非常成功，但首先需要文化上的转变。国民保健制度采纳这样的转变符合患者以及医疗专业人员的最大利益。
