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Learning from adverse events and near misses.

作者信息

Greenberg Caprice C

机构信息

Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA 02115, USA.

出版信息

J Gastrointest Surg. 2009 Jan;13(1):3-5. doi: 10.1007/s11605-008-0693-6. Epub 2008 Sep 17.

DOI:10.1007/s11605-008-0693-6
PMID:18797974
Abstract
摘要

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A facilitated survey instrument captures significantly more anesthesia events than does traditional voluntary event reporting.与传统的自愿事件报告相比，一种便利的调查工具能显著捕获更多的麻醉事件。
Anesthesiology. 2007 Dec;107(6):909-22. doi: 10.1097/01.anes.0000291440.08068.21.
2
Analysis of surgical errors in closed malpractice claims at 4 liability insurers.对4家责任保险公司已结案医疗事故索赔中的手术失误进行分析。
Surgery. 2006 Jul;140(1):25-33. doi: 10.1016/j.surg.2006.01.008.
3
Prospective assessment of intraoperative precursor events during cardiac surgery.
利用专家评估进行自动化计算机评分来建模手术技术技能。
Ann Surg. 2019 Mar;269(3):574-581. doi: 10.1097/SLA.0000000000002478.
4
Where are my instruments? Hazards in delivery of surgical instruments.我的器械在哪里？手术器械交付中的风险。
Surg Endosc. 2016 Jul;30(7):2728-35. doi: 10.1007/s00464-015-4537-7. Epub 2015 Oct 20.
5
A RFID specific participatory design approach to support design and implementation of real-time location systems in the operating room.一种支持手术室实时定位系统设计与实施的特定于射频识别的参与式设计方法。
J Med Syst. 2015 Jan;39(1):168. doi: 10.1007/s10916-014-0168-0. Epub 2014 Dec 14.
6
Near-miss events are really missed! Reflections on incident reporting in a department of pediatric surgery.险些发生的事件实则被忽视了！对小儿外科某科室事件报告的反思
Pediatr Surg Int. 2012 Apr;28(4):405-10. doi: 10.1007/s00383-011-3047-5. Epub 2012 Jan 7.
7
Development of a measure of patient safety event learning responses.患者安全事件学习反应衡量指标的制定。
Health Serv Res. 2009 Dec;44(6):2123-47. doi: 10.1111/j.1475-6773.2009.01021.x. Epub 2009 Sep 2.
心脏手术期间术中前驱事件的前瞻性评估。
Eur J Cardiothorac Surg. 2006 Apr;29(4):447-55. doi: 10.1016/j.ejcts.2006.01.001. Epub 2006 Feb 23.
4
A prospective study of patient safety in the operating room.一项关于手术室患者安全的前瞻性研究。
Surgery. 2006 Feb;139(2):159-73. doi: 10.1016/j.surg.2005.07.037.
5
Human factors and cardiac surgery: a multicenter study.人为因素与心脏手术：一项多中心研究。
J Thorac Cardiovasc Surg. 2000 Apr;119(4 Pt 1):661-72. doi: 10.1016/S0022-5223(00)70006-7.