Johnson C W
Department of Computing Science, University of Glasgow, UK.
Qual Saf Health Care. 2003 Dec;12 Suppl 2(Suppl 2):ii64-7. doi: 10.1136/qhc.12.suppl_2.ii64.
Incident reporting has been proposed as an important means of identifying and addressing the causes of human error in medicine, and initiatives to implement these schemes have been set up in many countries. However, incident reporting has its limitations. Many people have been too ready to believe the overstated claims about the effectiveness of incident reporting in other domains. Others have not listened to the more limited claims made by the operators of existing systems in aviation and in organizational health and safety applications. This paper argues that more attention should be paid to the problems of eliciting incident reports from a broad spectrum of healthcare workers. It is also argued that more sophisticated computation support should be recruited so that clinicians do not have to learn complex command languages when they want to search for common factors in those incidents that are submitted.
事件报告已被提议作为识别和解决医学中人为错误原因的重要手段，许多国家已启动实施这些计划的举措。然而，事件报告有其局限性。许多人过于轻易地相信了在其他领域中关于事件报告有效性的夸大说法。其他人则没有听取航空领域以及组织健康与安全应用中现有系统运营者提出的较为有限的说法。本文认为，应更加关注从广泛的医护人员中获取事件报告的问题。同时还认为，应采用更复杂的计算支持，以便临床医生在想要查找已提交事件中的共同因素时，不必学习复杂的命令语言。
