Department of Medical Imaging, University Health Network, 33540Toronto General Hospital, Toronto, Ontario, Canada.
Chief Patient Safety Officer and VP Quality & Safety, University Health Network, Toronto, Ontario, Canada.
Can Assoc Radiol J. 2020 Nov;71(4):528-535. doi: 10.1177/0846537119899215. Epub 2020 Feb 26.
While there are limited data on error in interventional radiology (IR), the literature so far indicates that many errors in IR are potentially preventable. Yet, understanding the sources for error and implementing effective countermeasures can be challenging. Traditional methods for reducing error such as increased vigilance and new policies may be effective but can also contribute to an "error cycle." A hierarchy of effectiveness for patient safety interventions is outlined, and the characteristics of "high-reliability" organizations in other "high-risk" industries are examined for clues that could be implemented in IR. The evidence behind team error reduction strategies such as checklists is considered along with individual approaches such as "slowing down when you should." However, error in medicine is inevitable, and this article also seeks to outline an evidence-based approach to managing the psychological impact of being involved in medical error as a physician.
虽然介入放射学（IR）中的错误数据有限，但迄今为止的文献表明，IR 中的许多错误是可以预防的。然而，了解错误的来源并实施有效的对策可能具有挑战性。减少错误的传统方法，如提高警惕性和新政策，可能是有效的，但也可能导致“错误循环”。概述了患者安全干预措施的有效性层次结构，并研究了其他“高风险”行业中“高可靠性”组织的特征，以期为 IR 中实施提供线索。还考虑了团队减少错误策略（如检查表）背后的证据，以及个人方法（如“该慢的时候慢下来”）。然而，医学中的错误是不可避免的，本文还试图概述一种基于证据的方法，以管理作为医生参与医疗错误的心理影响。
