Su Lillian
Division of Critical Care Medicine and the Board of Visitors Simulation Program, Children׳s National Health System, 111 Michigan Ave M4813, Washington, DC 20010.
Curr Probl Pediatr Adolesc Health Care. 2015 Dec;45(12):367-9. doi: 10.1016/j.cppeds.2015.10.004. Epub 2015 Nov 11.
Since humans are an integral part of healthcare delivery, it is appropriate to understand how human nature and human error impact patient safety. A thorough understanding of the interactions between humans and the medical environment could help decrease errors that result in patient harm. This article describes some of our findings from a study that revealed unexpected behaviors which were documented on video during critical events (cardiac arrests) in a pediatric cardiac intensive care unit (CICU). We changed our training process for cardiac arrests as well as our nurse staffing in the CICU based upon results of our study. We believe that the lessons learned in our CICU are generalizable to both inpatient and ambulatory settings. We also emphasize the importance of collaborating with social scientists to rigorously study innate maladaptive patterns of human behavior to determine strategies to mitigate "human factors" during acute medical crises.
由于人类是医疗服务不可或缺的一部分，因此了解人性和人为失误如何影响患者安全是恰当的。深入了解人类与医疗环境之间的相互作用有助于减少导致患者伤害的错误。本文描述了我们一项研究的一些发现，该研究揭示了在小儿心脏重症监护病房（CICU）的危急事件（心脏骤停）期间视频记录的意外行为。基于我们的研究结果，我们改变了心脏骤停的培训流程以及CICU的护士人员配置。我们相信，我们在CICU学到的经验教训适用于住院和门诊环境。我们还强调与社会科学家合作的重要性，以便严格研究人类行为的固有适应不良模式，从而确定在急性医疗危机期间减轻“人为因素”的策略。
