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An Outbreak of Clostridium difficile Ribotype 027 Associated with Length of Stay in the Intensive Care Unit and Use of Selective Decontamination of the Digestive Tract: A Case Control Study.艰难梭菌核糖体分型027暴发与重症监护病房住院时间及消化道选择性去污的使用：一项病例对照研究
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3
Transmission of Mycobacterium chimaera from Heater-Cooler Units during Cardiac Surgery despite an Ultraclean Air Ventilation System.尽管采用了超净空气通风系统，心脏手术期间仍有偶发分枝杆菌从热交换器单元传播。
Emerg Infect Dis. 2016 Jun;22(6):1008-13. doi: 10.3201/eid2206.160045. Epub 2016 Jun 15.
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Emergence and global spread of epidemic healthcare-associated Clostridium difficile.传染病相关艰难梭菌的出现和全球传播。
Nat Genet. 2013 Jan;45(1):109-13. doi: 10.1038/ng.2478. Epub 2012 Dec 9.
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The normalization of deviance in healthcare delivery.医疗服务中异常行为的常态化。
Bus Horiz. 2010;53(2):139. doi: 10.1016/j.bushor.2009.10.006.
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Clostridium difficile infection: new developments in epidemiology and pathogenesis.艰难梭菌感染：流行病学与发病机制的新进展
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Clinical microsystems, part 1. The building blocks of health systems.临床微系统，第1部分。卫生系统的组成要素。
Jt Comm J Qual Patient Saf. 2008 Jul;34(7):367-78. doi: 10.1016/s1553-7250(08)34047-1.
8
Violations and migrations in health care: a framework for understanding and management.医疗保健中的违规行为与人员流动：理解与管理框架
Qual Saf Health Care. 2006 Dec;15 Suppl 1(Suppl 1):i66-71. doi: 10.1136/qshc.2005.015982.

突发专栏20：疫情爆发是展现了人类判断和行为交织错误的人为灾难吗？

Outbreak Column 20: are outbreaks man-made disasters that display intertwined errors of human judgement and behaviour?

作者信息

Curran Evonne T

机构信息

Honorary Senior Research Fellow, School of Health and Life Sciences, Glasgow Caledonian University, Independent Infection Prevention Nurse Consultant, UK.

出版信息

J Infect Prev. 2017 Jul;18(4):199-206. doi: 10.1177/1757177416683264. Epub 2017 Jan 17.

DOI:10.1177/1757177416683264
PMID:28989528
原文链接:https://pmc.ncbi.nlm.nih.gov/articles/PMC5496687/
Abstract

Man-made disasters are reported to have five intertwined errors of human judgement and behaviour. As outbreaks are essentially man-made disasters, the cited intertwined errors of engineering overreach, smooth sailing fallacy, insider view, risk-seeking incentives and social-herding were looked for in five notable outbreaks of infection. Engineering overreach was found to be the most identifiable error. The purpose of this reflective exercise was to turn hindsight into foresight and determine the intertwined levels of safety behaviour needed to prevent any future pathogen emerging to produce healthcare disasters.

摘要

据报道，人为灾难存在五个相互交织的人类判断和行为错误。由于疫情本质上属于人为灾难，我们在五次重大感染疫情中寻找了文中提到的工程过度、一帆风顺谬误、内部视角、冒险激励和社会从众等相互交织的错误。工程过度被发现是最容易识别的错误。这项反思性工作的目的是将事后诸葛亮转变为未雨绸缪，并确定预防未来任何病原体引发医疗灾难所需的安全行为交织水平。