Schimpff Stephen C
University of Maryland School of Medicine, Baltimore, Maryland, USA.
Surg Innov. 2007 Jun;14(2):127-35. doi: 10.1177/1553350607301746.
The 1999 Institute of Medicine report To Err Is Human put a spotlight on death from preventable medical errors. Surgically related errors are second only to medication errors as the most frequent cause of error-related death. Although many hospitals have ongoing programs to improve medication safety, most hospitals are not focused in a meaningful way on operating room (OR) safety despite the import of the OR to the hospital's finances and despite clearly efficacious available technologies. The perioperative environment is a high-risk area with high velocity, high complexity, and high stakes. OR errors lead to disproportionately more harm than errors elsewhere in the hospital. Actual adverse events are relatively rare in any given OR suite, but near misses are rather common. It is possible to learn much from evaluating near misses (along with adverse events) with root-cause analyses and then instituting changes in processes and systems to assist humans from making their inevitable errors. This article outlines approaches that when combined can markedly improve safety in the OR.
1999年医学研究所发布的《人皆会犯错》报告聚焦于可预防医疗差错导致的死亡。手术相关差错是仅次于用药差错的导致与差错相关死亡的最常见原因。尽管许多医院都在持续开展提高用药安全的项目，但大多数医院并未切实关注手术室安全，尽管手术室对医院财务至关重要，且有明显有效的现有技术。围手术期环境是一个高风险区域，具有高速度、高复杂性和高风险。手术室差错造成的危害比医院其他地方的差错大得多。在任何特定的手术室中，实际不良事件相对较少，但险些发生的差错却相当常见。通过对险些发生的差错（以及不良事件）进行根本原因分析，然后对流程和系统进行改进，以帮助人们避免不可避免的错误，从中可以学到很多东西。本文概述了一些方法，这些方法结合起来可以显著提高手术室的安全性。
