Academic Department of Oto-Rhino-Laryngology, National University of Ireland, Newcastle Road, Galway, Ireland.
Surgeon. 2010 Apr;8(2):93-5. doi: 10.1016/j.surge.2009.10.004. Epub 2009 Dec 5.
Studies estimate that a degree of error occurs in 5-15% of all hospital admissions, with 45% of errors occurring in the operating theatre. Staffing limitations, high turnover rates, site and side-specific surgical procedures, make operating theatres a high-risk environment. Valuable lessons may be learned from the aviation experience with error management. With over 70% of air-crashes occurring due to human rather than technical error, the Human Factors Approach to error recognises the potential for errors occurring due to human limitations, such as stress and fatigue. It encourages error reporting in a non-punitive environment, where it is seen as a valuable source of information, facilitating education and future error prevention. Errors in healthcare and surgery however, have been traditionally associated with secrecy and embarrassment, often reaching an unsatisfactory endpoint with no resultant education. Application of the Human Factors Approach to error management in healthcare, can only serve to improve safety standards in our hospitals and satisfy ever-increasing public expectations.
研究估计,所有住院治疗中有 5-15%的程度存在错误,其中 45%的错误发生在手术室。人员配备限制、高周转率、特定部位和特定手术程序使手术室成为高风险环境。从航空业的错误管理经验中可以吸取宝贵的教训。由于人为而非技术错误,70%以上的空难发生,人为因素方法承认由于人为限制(如压力和疲劳)可能会出现错误。它鼓励在非惩罚性环境中报告错误,将其视为有价值的信息来源,促进教育和未来的错误预防。然而,医疗保健和手术中的错误传统上与保密和尴尬有关,往往以没有教育结果的不满意结局告终。将人为因素方法应用于医疗保健中的错误管理,只会提高我们医院的安全标准,并满足公众日益增长的期望。