Department of Human Sciences, Loughborough University, Loughborough, UK.
Ergonomics. 2009 Oct;52(10):1196-205. doi: 10.1080/00140130903045629.
This paper describes a systems ergonomics analysis of the recent outbreaks of Clostridium difficile, which occurred over the period 2005-07 within the UK Maidstone and Tunbridge Wells NHS Trust. The analysis used documents related to the outbreak, alongside the construction of a system model in order to probe deeper into the nature of contributory factors within the Trust. The findings from the analysis demonstrate the value of looking further at cross-level and whole-system aspects of infection outbreaks. In particular, there is a need for further study of the causal relationships that exist between hospital management and clinical management levels within the system. Finally, the paper discusses ways forward and strategies that could be adopted in order to limit the outbreak of hospital-related infections and shape future research. The approach used for the system analysis described in the paper could be used by healthcare practitioners and ergonomists to probe deeper into the causes of infection outbreaks and to extend the scope of interventions aimed at preventing their occurrence.
本文对 2005 年至 2007 年期间在英国梅德斯通和汤布里奇韦尔斯国民保健信托基金内爆发的艰难梭菌感染事件进行了系统工效学分析。该分析使用了与疫情相关的文件，并构建了一个系统模型，以便更深入地探究信托基金内促成因素的本质。分析结果表明，有必要进一步研究感染爆发的跨层次和全系统方面。特别是，需要进一步研究系统内医院管理和临床管理层面之间存在的因果关系。最后，本文讨论了未来的发展方向和可采用的策略，以限制医院相关感染的爆发，并为未来的研究提供参考。本文所述系统分析所采用的方法可被医疗保健从业者和工效学家用于更深入地探究感染爆发的原因，并扩展旨在预防其发生的干预措施的范围。
