不良事件发生的瑞士奶酪模型——填补漏洞
The Swiss cheese model of adverse event occurrence--Closing the holes.
作者信息
Stein James E, Heiss Kurt
机构信息
Children's Hospital Los Angeles, 4650 Sunset Blvd, MS 100, Los Angeles, California 90027.
Children's Hospital Los Angeles, 4650 Sunset Blvd, MS 100, Los Angeles, California 90027.
出版信息
Semin Pediatr Surg. 2015 Dec;24(6):278-82. doi: 10.1053/j.sempedsurg.2015.08.003.
Traditional surgical attitude regarding error and complications has focused on individual failings. Human factors research has brought new and significant insights into the occurrence of error in healthcare, helping us identify systemic problems that injure patients while enhancing individual accountability and teamwork. This article introduces human factors science and its applicability to teamwork, surgical culture, medical error, and individual accountability.
传统外科对于失误和并发症的态度一直聚焦于个人过失。人因学研究为医疗保健领域失误的发生带来了全新且重要的见解，帮助我们识别那些在伤害患者的系统性问题，同时增强个人责任感和团队协作。本文介绍了人因学及其在团队协作、外科文化、医疗失误和个人责任感方面的适用性。
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