Collins Susan J, Newhouse Robin, Porter Jody, Talsma AkkeNeel
AORN J. 2014 Jul;100(1):65-79.e5. doi: 10.1016/j.aorn.2013.07.024.
Approximately 2,700 patients are harmed by wrong-site surgery each year. The World Health Organization created the surgical safety checklist to reduce the incidence of wrong-site surgery. A project team conducted a narrative review of the literature to determine the effectiveness of the surgical safety checklist in correcting and preventing errors in the OR. Team members used Swiss cheese model of error by Reason to analyze the findings. Analysis of results indicated the effectiveness of the surgical checklist in reducing the incidence of wrong-site surgeries and other medical errors; however, checklists alone will not prevent all errors. Successful implementation requires perioperative stakeholders to understand the nature of errors, recognize the complex dynamic between systems and individuals, and create a just culture that encourages a shared vision of patient safety.
每年约有2700名患者因手术部位错误而受到伤害。世界卫生组织制定了手术安全检查表以降低手术部位错误的发生率。一个项目团队对文献进行了叙述性综述，以确定手术安全检查表在纠正和预防手术室错误方面的有效性。团队成员使用里森的瑞士奶酪模型来分析研究结果。结果分析表明手术检查表在降低手术部位错误和其他医疗错误发生率方面是有效的；然而，仅靠检查表并不能预防所有错误。成功实施需要围手术期的利益相关者了解错误的本质，认识到系统与个人之间复杂的动态关系，并营造一种公正的文化，鼓励对患者安全形成共同愿景。
