Parker D, Lawton R
Department of Psychology, University of Manchester, Manchester M13 9PL, UK. Parker@
Qual Saf Health Care. 2003 Dec;12(6):453-7. doi: 10.1136/qhc.12.6.453.
In the past it has sometimes been assumed in health care that all adverse events involve individual incompetence and therefore blameworthiness, an assumption that is likely to hinder the development of comprehensive and honest incident reporting systems. At the same time, a full understanding of adverse events in healthcare systems requires that distinctions are drawn between a variety of error types, each of which has different origins and demands different strategies for remediation. In this paper a range of cognitive biases identified by psychologists is described. Examples are given of these biases, which are naturally employed in trying to understand our own behaviour and that of others, and therefore affect our understanding of adverse events. It is suggested that awareness of these biases, which form part of our normal thinking, should help to avoid a narrow focus on individual culpability and facilitate a more sophisticated approach to the investigation of adverse events.
过去，医疗保健领域有时会认为所有不良事件都涉及个人能力不足，因此应受到指责，这种假设可能会阻碍全面且如实的事件报告系统的发展。与此同时，要全面理解医疗系统中的不良事件，就需要区分各种不同类型的错误，每种错误都有不同的根源，且需要不同的补救策略。本文描述了心理学家所识别出的一系列认知偏差。文中给出了这些偏差的示例，它们在试图理解我们自己及他人的行为时会自然出现，因而会影响我们对不良事件的理解。有人提出，认识到这些作为我们正常思维一部分的偏差，应有助于避免狭隘地关注个人罪责，并促进以更复杂的方式来调查不良事件。
