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高可靠性组织——用药安全

High Reliability Organizations--Medication Safety.

作者信息

Yip Luke, Farmer Brenna

机构信息

Rocky Mountain Poison and Drug Center, Denver Health, 777 Bannock Street, MC 0180, Denver, CO, 80204-4507, USA,

出版信息

J Med Toxicol. 2015 Jun;11(2):257-61. doi: 10.1007/s13181-015-0471-2.

Abstract

High reliability organizations (HROs), such as the aviation industry, successfully engage in high-risk endeavors and have low incidence of adverse events. HROs have a preoccupation with failure and errors. They analyze each event to effect system wide change in an attempt to mitigate the occurrence of similar errors. The healthcare industry can adapt HRO practices, specifically with regard to teamwork and communication. Crew resource management concepts can be adapted to healthcare with the use of certain tools such as checklists and the sterile cockpit to reduce medication errors. HROs also use The Swiss Cheese Model to evaluate risk and look for vulnerabilities in multiple protective barriers, instead of focusing on one failure. This model can be used in medication safety to evaluate medication management in addition to using the teamwork and communication tools of HROs.

摘要

高可靠性组织(HROs),如航空业,成功地从事高风险活动且不良事件发生率较低。高可靠性组织关注失败和错误。他们分析每一个事件以实现全系统的变革,试图减少类似错误的发生。医疗行业可以采用高可靠性组织的做法,特别是在团队合作和沟通方面。机组资源管理概念可以通过使用某些工具(如检查表和无菌驾驶舱)应用于医疗领域,以减少用药错误。高可靠性组织还使用瑞士奶酪模型来评估风险,并在多个防护屏障中寻找漏洞,而不是只关注一个故障。除了使用高可靠性组织的团队合作和沟通工具外,该模型还可用于药物安全领域,以评估药物管理情况。

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引用本文的文献

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