Habraken M M P, van der Schaaf T W
Eindhoven University of Technology, Eindhoven, The Netherlands.
Qual Saf Health Care. 2010 Feb;19(1):37-41. doi: 10.1136/qshc.2007.026187.
Systematic analysis of error recovery can provide hospitals with important information to help them improve their ability to detect and correct errors. Because errors will always crop up and 100% safety can never be achieved, hospitals should be able to prevent patient harm by timely and effective error recovery.
In this study, failed, missed and absent recovery opportunities were identified in 52 medication errors which all resulted in severe patient harm or patient death. For all identified recovery opportunities, the underlying failure factors were identified and classified according to the Eindhoven classification model. Those failure factors represent negative influences on error recovery.
The number of recovery opportunities per error ranged from 0 to 11; on average, 2.4 recovery opportunities were identified. Of 127 identified recovery opportunities, 94 (74%) were planned and 33 (26%) were unplanned or ad hoc. Most failure factors underlying the planned recovery opportunities were organisational failure factors; most failure factors underlying the unplanned recovery opportunities were human failure factors.
From this study, it can be concluded that actual accidents can be used as an alternative data source to near misses for the analysis and understanding of error recovery. By using both sources, hospitals can enhance their resilience by reinforcing the positive influences on error recovery as well as reducing the negative ones. Together with traditional error reduction methodologies, which only concentrate on eliminating failure factors, hospitals thus have numerous opportunities to improve patient safety.
对差错恢复进行系统分析可为医院提供重要信息，以帮助其提高差错检测和纠正能力。由于差错总会出现，且永远无法实现100%的安全，医院应能够通过及时有效的差错恢复来防止患者受到伤害。
在本研究中，在52起均导致严重患者伤害或患者死亡的用药差错中识别出了失败、遗漏和未出现的恢复机会。对于所有识别出的恢复机会，根据埃因霍温分类模型识别并分类潜在的失败因素。这些失败因素代表了对差错恢复的负面影响。
每起差错的恢复机会数量从0到11不等；平均识别出2.4个恢复机会。在127个识别出的恢复机会中，94个（74%）是计划内的，33个（26%）是计划外的或临时的。计划内恢复机会的大多数潜在失败因素是组织性失败因素；计划外恢复机会的大多数潜在失败因素是人为失败因素。
从本研究可以得出结论，实际事故可作为分析和理解差错恢复的未遂事件的替代数据源。通过使用这两种数据源，医院可以通过加强对差错恢复的积极影响以及减少负面影响来增强其恢复力。与仅专注于消除失败因素的传统差错减少方法一起，医院因此有众多机会提高患者安全。
