Doerhoff Rebecca, Garrison Barbara
Department of Quality and Safety (Ms Doerhoff) and Department of Nursing; and Newborn Intensive Care Unit (Ms Garrison), St Louis Children's Hospital, St Louis, Missouri.
J Perinat Neonatal Nurs. 2015 Apr-Jun;29(2):162-9. doi: 10.1097/JPN.0000000000000105.
Human factors have been identified as the most frequent cause of and contributory factor to sentinel events. Many human factor errors are preventable, and neonatal nurses are instrumental at the point of care in working with system leaders to identify various problems and potentially safe practices that can be hardwired into daily practice. This article defines human factors that often occur in daily processes of care in many neonatal intensive care units (NICU) and specific evidence-based strategies to implement to reduce preventable human errors. Human factor evidence from other high-risk industries is relevant to healthcare and can be applied to the complex adaptive environment of the NICU. Nurses need to be mindful of their complex environment and to have a basic understanding of the role of human factors principles.
人为因素已被确定为警讯事件最常见的原因和促成因素。许多人为因素导致的错误是可以预防的，新生儿护士在护理现场对于与系统领导者合作识别各种问题以及可融入日常实践的潜在安全做法起着重要作用。本文定义了许多新生儿重症监护病房（NICU）日常护理过程中经常出现的人为因素，以及为减少可预防的人为错误而实施的具体循证策略。来自其他高风险行业的人为因素证据与医疗保健相关，可应用于NICU的复杂适应环境。护士需要留意其复杂的环境，并对人为因素原则的作用有基本的了解。
