Lazarovici M, Trentzsch H, Prückner S
Institut für Notfallmedizin und Medizinmanagement, Klinikum der Universität München, Ludwig-Maximilians-Universität, Schillerstr. 53, 80336, München, Deutschland.
Anaesthesist. 2017 Jan;66(1):63-80. doi: 10.1007/s00101-016-0261-5.
The concept of human factors is commonly used in the context of patient safety and medical errors, all too often ambiguously. In actual fact, the term comprises a wide range of meanings from human-machine interfaces through human performance and limitations up to the point of working process design; however, human factors prevail as a substantial cause of error in complex systems. This article presents the full range of the term human factors from the (emergency) medical perspective. Based on the so-called Swiss cheese model by Reason, we explain the different types of error, what promotes their emergence and on which level of the model error prevention can be initiated.
人为因素的概念常用于患者安全和医疗差错的背景下，而且常常含混不清。实际上，该术语涵盖了从人机界面到人的表现与局限性，直至工作流程设计等广泛的含义；然而，在复杂系统中，人为因素是导致差错的一个重要原因。本文从（急诊）医学角度阐述了人为因素这一术语的全部内容。基于瑞森提出的所谓瑞士奶酪模型，我们解释了不同类型的差错、促使其出现的因素以及在该模型的哪个层面可以启动差错预防。
