Skinner Lori, Tripp Terrance R, Scouler David, Pechacek Judith M
Creat Nurs. 2015;21(3):179-85. doi: 10.1891/1078-4535.21.3.179.
According to the Institute of Medicine (IOM, 1999, p. 1), "Medical errors can be defined as the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim." The current health care culture is disjointed, as evidenced by a lack of consistent reporting standards for all providers; provider licensing pays little attention to errors, and there are no financial incentives to improve safety (IOM, 1999). Many errors in health care are preventable. "Near misses" and adverse events that do occur can offer insight on how to improve practice and prevent future events. The aim of this article is to better understand underreporting of errors in health care, to present a model of change that increases voluntary error reporting, and to discuss the role nurse executives play in creating a culture of safety. This article explores how high reliability organizations such as aviation improve safety through enhanced error reporting, culture change, and teamwork.
根据医学研究所(IOM,1999年,第1页)的定义,“医疗差错可定义为计划好的行动未能按预期完成,或使用错误的计划来实现目标。”当前的医疗文化是脱节的,所有医疗服务提供者缺乏统一的报告标准就证明了这一点;医疗服务提供者的执照发放很少关注差错,而且没有改善安全状况的经济激励措施(IOM,1999年)。许多医疗差错是可以预防的。发生的“险些发生的差错”和不良事件能够为如何改进医疗实践和预防未来事件提供见解。本文的目的是更好地理解医疗差错报告不足的情况,提出一个能增加自愿差错报告的变革模型,并讨论护士管理人员在营造安全文化中所起的作用。本文探讨了诸如航空业等高可靠性组织如何通过加强差错报告、文化变革和团队合作来提高安全性。