Ruchlin Hirsch S, Dubbs Nicole L, Callahan Mark A
Weill Medical College, Cornell University, New York, USA.
J Healthc Manag. 2004 Jan-Feb;49(1):47-58; discussion 58-9.
The publication of To Err Is Human has highlighted concern for patient safety. Attention to date has focused primarily on micro issues such as minimizing medication errors and adverse drug reactions, improving select aspects of care, and reducing diagnostic and treatment errors. However, attention is also required to a macro issue--an organization's culture and the level of leadership required to create a culture. This article discusses the concepts of culture and leadership and summarizes two paradigms that are useful in understanding the precursors of medical errors and developing interventions to prevent them: normal accident theory and high-reliability organization theory. It also delineates approaches to instilling a safety culture. Normal accident theory asserts that errors result from system failures. An important element of this perspective is the need for a system that collects, analyzes, and disseminates information from incidents and near misses as well as regular proactive checks on the system's vital signs. Four subcultures are necessary to support such an environment: a reporting culture, a just culture, a flexible culture, and a learning culture. High-reliability organization theory posits that accidents occur because individuals who operate and manage complex systems are themselves not sufficiently complex to sense and anticipate the problems generated by the system. Lessons learned from high-reliability organizations indicate that a safety culture is supported by migrated distributed decision making, management by exception or negotiation, and fostering a sense of the "big picture." Lessons from other industries are also shared in this article.
《人皆有过》的出版引发了对患者安全的关注。迄今为止，注意力主要集中在一些微观问题上，比如尽量减少用药错误和药物不良反应、改善某些护理环节以及减少诊断和治疗错误。然而，还需要关注一个宏观问题——组织文化以及营造这种文化所需的领导力水平。本文讨论了文化和领导力的概念，并总结了两种有助于理解医疗差错的成因以及制定预防措施的范式：常态事故理论和高可靠性组织理论。文章还阐述了灌输安全文化的方法。常态事故理论认为，差错是由系统故障导致的。这一观点的一个重要要素是需要一个能够收集、分析和传播来自事故及未遂事故的信息，以及对系统关键指标进行定期主动检查的系统。要营造这样一种环境，需要四种亚文化：报告文化、公正文化、灵活文化和学习文化。高可靠性组织理论认为，事故之所以发生，是因为操作和管理复杂系统的人员自身不够复杂，无法感知和预见系统产生的问题。从高可靠性组织吸取的经验表明，安全文化得到以下因素的支持：分散式决策、例外或协商管理以及培养全局意识。本文还分享了其他行业的经验教训。
