Bartz Hans-Jürgen
Leitung GB QM und klinisches Prozessmanagement, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, Gebäude O 13, 20246, Hamburg, Deutschland,
Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz. 2015 Jan;58(1):45-53. doi: 10.1007/s00103-014-2073-6.
Systemic error analysis plays a key role in clinical risk management. This includes all clinical and administrative activities which identify, assess and reduce the risks of damage to patients and to the organization. The clinical risk management is an integral part of quality management. This is also the policy of the Federal Joint Committee (Gemeinsamer Bundesausschuss, G-BA) on the fundamental requirements of an internal quality management. The goal of all activities is to improve the quality of medical treatment and patient safety. Primarily this is done by a systemic analysis of incidents and errors. A results-oriented systemic error analysis needs an open and unprejudiced corporate culture. Errors have to be transparent and measures to improve processes have to be taken. Disciplinary action on staff must not be part of the process. If these targets are met, errors and incidents can be analyzed and the process can create added value to the organization. There are some proven instruments to achieve that. This paper discusses in detail the error and risk analysis (ERA), which is frequently used in German healthcare organizations. The ERA goes far beyond the detection of problems due to faulty procedures. It focuses on the analysis of the following contributory factors: patient factors, task and process factors, individual factors, team factors, occupational and environmental factors, psychological factors, organizational and management factors and institutional context. Organizations can only learn from mistakes by analyzing these factors systemically and developing appropriate corrective actions. This article describes the fundamentals and implementation of the method at the University Medical Center Hamburg-Eppendorf.
系统误差分析在临床风险管理中起着关键作用。这包括所有识别、评估和降低对患者及组织造成损害风险的临床和管理活动。临床风险管理是质量管理的一个组成部分。这也是联邦联合委员会（Gemeinsamer Bundesausschuss，G-BA）关于内部质量管理基本要求的政策。所有活动的目标是提高医疗质量和患者安全。主要通过对事件和误差进行系统分析来实现这一目标。以结果为导向的系统误差分析需要开放且无偏见的企业文化。误差必须透明，并且必须采取改进流程的措施。对员工的纪律处分不应成为该过程的一部分。如果达到这些目标，就可以对误差和事件进行分析，并且该过程可以为组织创造附加值。有一些经过验证的工具可以实现这一点。本文详细讨论了德国医疗保健机构中经常使用的误差和风险分析（ERA）。ERA远远超出了对因程序错误而产生问题的检测。它侧重于对以下促成因素进行分析：患者因素、任务和流程因素、个人因素、团队因素、职业和环境因素、心理因素、组织和管理因素以及机构背景。组织只有通过系统地分析这些因素并制定适当的纠正措施，才能从错误中吸取教训。本文介绍了该方法在汉堡-埃彭多夫大学医学中心的基本原理和实施情况。
