将系统事故分析纳入患者安全事件调查实践中。

Integrating systemic accident analysis into patient safety incident investigation practices.

机构信息

Human Factors and Complex Systems Group, Loughborough Design School, Loughborough University, Loughborough, UK.

出版信息

Appl Ergon. 2018 Oct;72:1-9. doi: 10.1016/j.apergo.2018.04.012. Epub 2018 Apr 30.

DOI:10.1016/j.apergo.2018.04.012

Abstract

There is growing awareness of the limitations of current practice regarding the investigation of patient safety incidents, including a reliance on Root Cause Analysis (RCA) and a lack of safety expertise. Human Factors and Ergonomics (HFE) can offer safety expertise and systemic approaches to incident analysis. However, HFE is underutilised in healthcare. This study aims to explore the integration of HFE systemic accident analysis into current practice. The study compares the processes and outputs of a current practice RCA-based incident analysis and a Systems Theoretic Accident Modelling and Processes (STAMP) analysis on the same medication error incident. The STAMP analysis was undertaken by two HFE researchers with the participation of twenty-one healthcare stakeholders. The STAMP-based approach guided healthcare stakeholders towards consideration of system design issues and remedial actions, going beyond the individual-based remedial actions proposed by the RCA. The study offers insights into how HFE can be integrated into current practice.

摘要

人们越来越意识到当前在调查患者安全事件方面的局限性，包括对根本原因分析（RCA）的依赖和缺乏安全专业知识。人为因素和工效学（HFE）可以提供安全专业知识和系统的方法来进行事件分析。然而，HFE 在医疗保健中的应用不足。本研究旨在探讨将 HFE 系统事故分析纳入当前实践。该研究比较了当前基于 RCA 的事件分析和基于系统理论事故建模和过程（STAMP）的分析对同一药物错误事件的过程和结果。STAMP 分析由两名 HFE 研究人员与二十一名医疗保健利益相关者共同进行。基于 STAMP 的方法引导医疗保健利益相关者考虑系统设计问题和补救措施，超越了 RCA 提出的基于个人的补救措施。该研究提供了有关如何将 HFE 纳入当前实践的见解。