Mohr Julie J, Barach Paul, Cravero Joseph P, Blike George T, Godfrey Marjorie M, Batalden Paul B, Nelson Eugene C
Department of Anesthesia and Critical Care, University of Chicago, Chicago, USA.
Jt Comm J Qual Saf. 2003 Aug;29(8):401-8. doi: 10.1016/s1549-3741(03)29048-1.
This article explores patient safety from a microsystems perspective and from an injury epidemiological perspective and shows how to embed safety into a microsystem's operations. MICROSYSTEMS PATIENT SAFETY SCENARIO: Allison, a 5-year-old preschooler with a history of "wheezy colds," and her mother interacted with several microsystems as they navigated the health care system. At various points, the system failed to address Allison's needs. The Haddon matrix provides a useful framework for analyzing medical failures in patient safety, setting the stage for developing countermeasures.
The case study shows the types of failures that can occur in complex medical care settings such as those associated with pediatric procedural sedation. Six patient safety principles, such as "design systems to identify, prevent, absorb, and mitigate errors," can be applied in a clinical setting. In response to this particular case, its subsequent analysis, and the application of microsystems thinking, the anesthesiology department of the Children's Hospital at Dartmouth developed the PainFree Program to provide optimal safety for sedated patients.
Safety is a property of a microsystem and it can be achieved only through thoughtful and systematic application of a broad array of process, equipment, organization, supervision, training, simulation, and team-work changes.
本文从微观系统视角和伤害流行病学视角探讨患者安全问题，并展示如何将安全融入微观系统的运作之中。
艾利森是一名5岁的学龄前儿童，有“喘息性感冒”病史，她和母亲在医疗保健系统中就医时与多个微观系统有互动。在不同环节，该系统未能满足艾利森的需求。哈顿矩阵为分析患者安全中的医疗失误提供了有用框架，为制定对策奠定了基础。
该案例研究展示了在诸如与儿科程序性镇静相关的复杂医疗环境中可能出现的失误类型。六条患者安全原则，如“设计系统以识别、预防、吸收和减轻错误”，可应用于临床环境。针对这一具体案例、其后续分析以及微观系统思维的应用，达特茅斯儿童医院麻醉科制定了“无痛计划”，为接受镇静的患者提供最佳安全保障。
安全是微观系统的一种属性，只有通过深思熟虑且系统地应用一系列广泛的流程、设备、组织、监督、培训、模拟和团队协作变革才能实现。
