University of Western Sydney, School of Nursing and Midwifery, Locked Bag 1797, Penrith South DC, New South Wales 1797, Australia.
Surg Clin North Am. 2012 Feb;92(1):101-15. doi: 10.1016/j.suc.2011.12.008.
This article discusses the limitations of root cause analysis (RCA) for surgical adverse events. Making sense of adverse events involves an appreciation of the unique features in a problematic situation, which resist generalization to other contexts. The top priority of adverse event investigations must be to inform the design of systems that help clinicians to adapt and respond effectively in real time to undesirable combinations of design, performance, and circumstance. RCAs can create opportunities in the clinical workplace for clinicians to reflect on local barriers and identify enablers of safe and reliable outcomes.
本文讨论了根本原因分析（RCA）在外科不良事件中的局限性。理解不良事件需要对特定情况下的独特特征有一个认识，这些特征难以推广到其他情境。不良事件调查的首要任务必须是为系统的设计提供信息，帮助临床医生实时有效地适应和应对设计、性能和环境的不理想组合。RCA 可以为临床工作场所的临床医生提供机会，反思当地的障碍，并确定安全可靠结果的促进因素。
