Henneman Elizabeth A, Gawlinski Anna
School of Nursing, University of Massachusetts, Amherst, MA, USA.
J Prof Nurs. 2004 May-Jun;20(3):196-201. doi: 10.1016/j.profnurs.2004.04.006.
Approximately 44,000 patients die each year as a result of medical errors. Nurses play an important role in ensuring patient safety and preventing adverse outcomes. As frontline providers of care, nurses are in key positions to intercept a medical error before it affects a patient. The Eindhoven model for investigating a "near-miss" situation has been used successfully in the chemical industry to elucidate the concept of human recovery, that is, the ability of operators to detect, localize, and correct system faults. In this article, we propose applying the Eindhoven model to the clinical setting, in which nurses play the role of operators by identifying, interrupting, and correcting medical errors. After describing the model, we present clinical scenarios to illustrate how it can be applied. More research is needed to explicate the nurse's role in managing medical errors. Interventions to decrease medical errors require insight into strategies that frontline clinicians can use to identify and mitigate potentially harmful incidents. The Eindhoven model can help researchers, administrators, and clinicians to conceptualize the role for nurses in developing such interventions.
每年约有44000名患者因医疗差错死亡。护士在确保患者安全和预防不良后果方面发挥着重要作用。作为一线护理人员，护士处于在医疗差错影响患者之前进行拦截的关键位置。埃因霍温调查“未遂事故”情况的模型已在化工行业成功应用，以阐明人类恢复的概念，即操作人员检测、定位和纠正系统故障的能力。在本文中，我们建议将埃因霍温模型应用于临床环境，在该环境中护士通过识别、中断和纠正医疗差错来扮演操作人员的角色。在描述该模型之后，我们给出临床案例来说明它是如何应用的。需要更多研究来阐明护士在管理医疗差错中的作用。减少医疗差错的干预措施需要深入了解一线临床医生可用于识别和减轻潜在有害事件的策略。埃因霍温模型可以帮助研究人员、管理人员和临床医生构思护士在制定此类干预措施中的作用。
