Clarke John R, Lerner Jeffrey C, Marella William
Drexel University Philadelphia, PA, USA.
Am J Med Qual. 2007 Sep-Oct;22(5):311-8. doi: 10.1177/1062860607304743.
We review what leaders of health care systems, including chief executive officers and board members, need to know to have "patient safety literacy" and do to make their systems safe. High reliability organizations produce reliable results that are not dependent on providers being perfect. Their characteristics include the commitment of leadership to safety as a system responsibility, with a culture of safety that decreases variability with standardized care and does not condone "at-risk behavior." A business case can be made for investing resources into systems that produce good outcomes reliably. Leaders must see patient safety problems as problems with their system, not with their employees. Leaders need to give providers information to make and monitor system progress. All medical errors, including near misses, and processes associated with all adverse events may provide information for system improvement. Improving systems should produce better long-term results than educating workers to be more careful.
我们回顾了医疗保健系统的领导者，包括首席执行官和董事会成员，为具备“患者安全素养”需要了解的内容以及为使他们的系统安全而需要采取的行动。高可靠性组织产生的可靠结果并不依赖于提供者的完美表现。其特点包括领导层将安全视为系统责任的承诺，拥有一种安全文化，这种文化通过标准化护理减少变异性，并且不容忍“冒险行为”。可以提出一个商业案例，即向能够可靠产生良好结果的系统投入资源。领导者必须将患者安全问题视为其系统的问题，而非员工的问题。领导者需要向提供者提供信息，以制定和监测系统进展。所有医疗差错，包括险些发生的差错，以及与所有不良事件相关的流程，都可为系统改进提供信息。改进系统应比教育员工更加谨慎能产生更好的长期效果。
