Department of Experimental Psychology, University of Oxford, 15 Parks Road, Oxford, OX1 3PW, UK.
Jane Carthey Consulting, London, UK.
Implement Sci. 2017 Dec 28;12(1):151. doi: 10.1186/s13012-017-0695-4.
Every safety-critical industry devotes considerable time and resource to investigating and analysing accidents, incidents and near misses. The systematic analysis of incidents has greatly expanded our understanding of both the causes and prevention of harm. These methods have been widely employed in healthcare over the last 20 years but are now subject to critique and reassessment. In this paper, we reconsider the purpose and value of incident analysis and methods appropriate to the healthcare of today.
The primary need for a revised vision of incident analysis is that healthcare itself is changing dramatically. People are living longer, often with multiple co-morbidities which are managed over very long timescales. Our vision of safety analysis needs to expand concomitantly to embrace much longer timescales. Rather than think only in terms of the prevention of specific incidents, we need to consider the balance of benefit, harm and risks over long time periods encompassing the social and psychological impact of healthcare as well as physical effects. We argued for major changes in our approach to the analysis of safety events: assume that patients and families will be partners in investigation and where possible engage them fully from the beginning, examine much longer time periods and assess contributory factors at different time points in the patient journey, be more proportionate and strategic in analysing safety issues, seek to understand success and recovery as well as failure, consider the workability of clinical processes as well as deviations from them and develop a much more structured and wide-ranging approach to recommendations.
Previous methods of incident analysis were simply adopted and disseminated with little research into the concepts, methods, reliability and outcomes of such analyses. There is a need for significant research and investment in the development of new methods. These changes are profound and will require major adjustments in both practical and cultural terms and research to explore and evaluate the most effective approaches.
每个安全关键行业都投入了大量的时间和资源来调查和分析事故、事件和未遂事件。对事件的系统分析极大地扩展了我们对伤害的原因和预防的理解。这些方法在过去 20 年中在医疗保健领域得到了广泛应用，但现在正受到批评和重新评估。在本文中，我们重新考虑事件分析的目的和价值以及适合当今医疗保健的方法。
重新审视事件分析的首要需求是医疗保健本身正在发生巨大变化。人们的寿命越来越长，通常患有多种合并症，这些合并症需要在很长的时间内进行管理。我们的安全分析视野需要相应地扩大，以涵盖更长的时间范围。我们不仅需要考虑特定事件的预防，还需要考虑在包含医疗保健的社会和心理影响以及身体影响的长时间段内，利益、危害和风险之间的平衡。我们主张对安全事件的分析方法进行重大改变：假设患者及其家属将成为调查的合作伙伴，并尽可能从一开始就充分参与其中，考察更长的时间段，并在患者就医过程的不同时间点评估促成因素，在分析安全问题时更加适度和具有战略性，寻求理解成功和恢复以及失败，考虑临床流程的可操作性以及对其的偏离，并制定更具结构性和广泛性的建议方法。
以前的事件分析方法只是被简单地采用和传播，而对这些分析的概念、方法、可靠性和结果的研究很少。需要对新方法的开发进行重大研究和投资。这些变化是深远的，将需要在实际和文化方面以及研究方面进行重大调整，以探索和评估最有效的方法。
