Brennan Peter A, Mitchell David A, Holmes Simon, Plint Simon, Parry David
Maxillofacial Unit, Portsmouth Hospitals NHS Trust, Portsmouth, PO6 3LY, UK.
Maxillofacial Unit, Bradford Teaching Hospitals NHS Foundation Trust, UK.
Br J Oral Maxillofac Surg. 2016 Jan;54(1):3-7. doi: 10.1016/j.bjoms.2015.09.023. Epub 2015 Nov 2.
Human error is as old as humanity itself and is an appreciable cause of mistakes by both organisations and people. Much of the work related to human factors in causing error has originated from aviation where mistakes can be catastrophic not only for those who contribute to the error, but for passengers as well. The role of human error in medical and surgical incidents, which are often multifactorial, is becoming better understood, and includes both organisational issues (by the employer) and potential human factors (at a personal level). Mistakes as a result of individual human factors and surgical teams should be better recognised and emphasised. Attitudes and acceptance of preoperative briefing has improved since the introduction of the World Health Organization (WHO) surgical checklist. However, this does not address limitations or other safety concerns that are related to performance, such as stress and fatigue, emotional state, hunger, awareness of what is going on situational awareness, and other factors that could potentially lead to error. Here we attempt to raise awareness of these human factors, and highlight how they can lead to error, and how they can be minimised in our day-to-day practice. Can hospitals move from being "high risk industries" to "high reliability organisations"?
人为失误与人类本身一样古老，是机构和个人犯错的一个重要原因。许多与导致失误的人为因素相关的研究都源于航空领域，在航空领域，失误不仅对造成失误的人，而且对乘客来说都可能是灾难性的。人为失误在医疗和外科事故中所起的作用正逐渐被人们所理解，这些事故往往是多因素导致的，包括机构问题（由雇主造成）和潜在的人为因素（个人层面）。个人因素和手术团队导致的失误应得到更好的认识和重视。自世界卫生组织（WHO）手术安全核对表推出以来，术前简报的态度和接受度有所改善。然而，这并未解决与手术表现相关的局限性或其他安全问题，如压力和疲劳、情绪状态、饥饿、对当前情况的认知（情境意识）以及其他可能导致失误的因素。在此，我们试图提高对这些人为因素的认识，强调它们如何导致失误，以及如何在日常实践中将其影响降至最低。医院能否从“高风险行业”转变为“高可靠性组织”？
