Schreiber P J
North American Dräger Company/Telford, Pa.
Anaesthesiol Reanim. 1990;15(5):287-97.
To reduce the risks to human health and life has become an increasing demand by society. Physicians and engineers must develop and adopt measures to reduce such risks. The administration of anesthesia may be viewed as a closed-loop control system consisting of three major components: the anaesthesia system, the patient, and the system operator. An analysis of human element involved in the administration of anaesthesia indicates that the human brain is best qualified to make intelligent decisions; however, the reliance on human vigilance for the continuing monitoring of monotonous processes is questionable. Human error may be divided into slips, mistakes and omissions, each of them requiring different means of prevention. The events during a critical incident follow a certain sequence. Preventive measures can best be prepared by analyzing this sequence. The designer of medical equipment has four different approaches available to prevent injury to the patient: (1) to design the equipment which prevents a human error, (2) to design the equipment that injury is not possible when the human error occurs, (3) to warn of the possibility of a human error, or (4) to monitor for changes of important parameters which indicate the beginning of a critical situation. The most important safety measure is an integrated monitoring system with centralized, structured alarm announciation.
降低对人类健康和生命的风险已成为社会日益增长的需求。医生和工程师必须制定并采取措施来降低此类风险。麻醉管理可被视为一个由三个主要部分组成的闭环控制系统：麻醉系统、患者和系统操作员。对麻醉管理中涉及的人为因素进行分析表明，人类大脑最有资格做出明智的决策；然而，依靠人类的警觉性来持续监测单调的过程是值得怀疑的。人为错误可分为失误、差错和疏忽，每种都需要不同的预防手段。危急事件中的事件遵循一定的顺序。通过分析这个顺序可以最好地制定预防措施。医疗设备的设计者有四种不同的方法来防止对患者造成伤害：（1）设计能防止人为错误的设备，（2）设计在发生人为错误时不可能造成伤害的设备，（3）警告人为错误的可能性，或（4）监测重要参数的变化，这些变化表明危急情况的开始。最重要的安全措施是一个具有集中式、结构化警报通知的综合监测系统。
