Spurgeon Peter, Flanagan Hugh, Cooke Matthew, Sujan Mark, Cross Stephen, Jarvis Rose
1 Medical School, Warwick University, UK.
2 Organisational Research Consultancy Network International (ORCNI), UK.
Health Serv Manage Res. 2017 May;30(2):85-93. doi: 10.1177/0951484817696211. Epub 2017 Mar 16.
Despite well meaning initiatives over decades, the percentage of inpatients suffering adverse events remains constant in most advanced health systems. The notion of incident reporting as used in other safety critical industries has proved far less effective in healthcare. This article describes a new patient safety paradigm in the search for improved patient safety in healthcare. Underpinned by a holistic use of human factors the Safer Clinical Systems programme involves a proactive, risk-based approach seeking to eliminate or control risk before it is converted to patient harm. The tools and techniques applied by healthcare professional in real-life settings are described along with the outcomes of a significant reduction in risk and improvement in safety culture as measured by the Safety Culture Index. The challenges of applying the approach are discussed but it is argued that important progress could be made if a critical mass of healthcare staff were helped to acquire skills in human factors.
尽管几十年来有诸多善意的举措，但在大多数先进的医疗体系中，住院患者遭遇不良事件的比例仍保持不变。事实证明，在其他对安全要求极高的行业中所采用的事件报告理念在医疗保健领域的效果要差得多。本文介绍了一种新的患者安全范式，旨在寻求提高医疗保健中的患者安全。基于对人为因素的全面运用，“更安全临床系统”计划采用一种积极主动、基于风险的方法，力求在风险转化为患者伤害之前消除或控制风险。文中描述了医疗保健专业人员在实际环境中应用的工具和技术，以及通过安全文化指数衡量得出的风险显著降低和安全文化改善的结果。文中讨论了应用该方法所面临的挑战，但有人认为，如果能帮助大量医疗保健人员掌握人为因素方面的技能，就可以取得重要进展。
