Palmieri Patrick A, Peterson Lori T, Ford Eric W
Duke University School of Nursnig, USA.
J Healthc Risk Manag. 2007;27(4):19-24. doi: 10.1002/jhrm.5600270405.
Iatrogenesis is a term typically reserved to express the state of ill health or the adverse outcome resulting from a medical intervention, or lack thereof. Three types of iatrogenesis are described in the literature: clinical, social and cultural. This paper introduces a fourth type, technological iatrogenesis, or emerging errors stimulated by the infusion of technological innovations into complex healthcare systems. While health information technologies (HIT) have helped to make healthcare safer, this has also produced contemporary varieties of iatrogenic errors and events. The potential pitfalls of technological innovations and risk management solutions to address these concerns are discussed. Specifically, failure mode effect analysis and root cause analysis are discussed as opportunities for risk managers to prevent problems and avert errors from becoming sentinel events.
医源性疾病是一个通常用于表达因医疗干预或缺乏医疗干预而导致的健康不佳状态或不良后果的术语。文献中描述了三种医源性疾病:临床医源性疾病、社会医源性疾病和文化医源性疾病。本文介绍了第四种类型,即技术医源性疾病,或因将技术创新引入复杂的医疗系统而引发的新出现的错误。虽然健康信息技术(HIT)有助于提高医疗安全性,但这也产生了当代各种医源性错误和事件。本文讨论了技术创新的潜在陷阱以及应对这些问题的风险管理解决方案。具体而言,讨论了失效模式影响分析和根本原因分析,认为这是风险管理者预防问题并避免错误演变为警讯事件的机会。