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[患者安全:关于该主题的数据及摆脱危机的方法]

[Patient safety: data on the topic and ways out of the crisis].

作者信息

Rall M

机构信息

Klinik für Anästhesiologie und operative Intensivmedizin, Klinikum am Steinenberg, Kreiskliniken Reutlingen, Reutlingen, Deutschland.

出版信息

Urologe A. 2012 Nov;51(11):1523-32. doi: 10.1007/s00120-012-2999-y.

Abstract

Studies have shown for many years that the cause of errors or patient injury is in a high proportion of cases to be found under human factors. Human factors include all those factors which determine the safety and capabilities of humans especially in complex situations or systems. Up to now this topic has barely been systematically dealt with in training and there is a large deficit. Modern simulation team training with systematic use of established principles of adult education and the implementation of crisis resource management (CRM) for teams can have enormous positive effects for patient safety. The concept of CRM for increasing human reliability is, however, barely used systematically for training. Simulation team training for critical events (not for emergency cases) is barely used. Professional performance at the highest level can only be expected from teams which regularly participate in team training for critical situations. In addition to simulation training with human factors, other aspects of patient safety are also essential. The concept of high reliability organizations (HRO) could make an important contribution in the sense of a safe hospital concept and includes the collection and analysis of critical incidents (critical incident reporting system CIRS) as well as the focus on the system of patient safety instead of individual persons and errors.

摘要

多年来的研究表明,在很大比例的病例中,错误或患者伤害的原因可归结为人为因素。人为因素包括所有那些决定人类安全性和能力的因素,尤其是在复杂情况或系统中。到目前为止,这个主题在培训中几乎没有得到系统的处理,存在很大的不足。现代模拟团队培训系统地运用成人教育的既定原则,并为团队实施危机资源管理(CRM),这对患者安全可能产生巨大的积极影响。然而,用于提高人类可靠性的CRM概念几乎没有系统地用于培训。针对关键事件(而非紧急情况)的模拟团队培训几乎未被采用。只有经常参加关键情况团队培训的团队才能期望达到最高水平的专业表现。除了人为因素的模拟培训外,患者安全的其他方面也至关重要。高可靠性组织(HRO)的概念可以在安全医院概念方面做出重要贡献,包括关键事件的收集和分析(关键事件报告系统CIRS)以及关注患者安全系统而非个人和错误。

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