Brennan P A, Holden C, Shaw G, Morris S, Oeppen R S
Department of Oral & Maxillofacial Surgery, Queen Alexandra Hospital, Portsmouth PO6 3LY, UK.
Heathrow Airport, Middlesex TW6 1EW, UK.
Br J Oral Maxillofac Surg. 2020 May;58(4):404-408. doi: 10.1016/j.bjoms.2020.01.030. Epub 2020 Feb 27.
It is increasingly being recognised that human factors can contribute to error in complex safety systems. Healthcare, however, has a long way to go before the promotion of training in, and awareness of, human factors will catch up with other high-risk organisations. A critical component that is deemed essential both for improving clinical performance and reducing medical error is situational awareness (SA). This is dynamic and can reduce quickly or be lost entirely, particularly when the workload is heavy. Tunnel vision, in which healthcare professionals concentrate on a single aspect of a patient's care, is just one example of reduced awareness that can be detrimental to safety. As in aviation and other high-risk organisations, a reduction in SA, if not recognised by individuals or the wider team, can lead to serious or potentially fatal outcomes. We therefore give an overview of SA and show how it can easily be reduced. We also suggest some simple but effective ways to improve it and in turn improve patient safety. We emphasise the importance of clinical teams looking out for each other, particularly in the operating theatre.
人们越来越认识到，人为因素可能导致复杂安全系统中的错误。然而，在促进人为因素培训和提高对其的认识方面，医疗保健领域要赶上其他高风险组织还有很长的路要走。情境意识（SA）被认为是提高临床绩效和减少医疗错误的关键要素。这是动态的，可能会迅速降低或完全丧失，尤其是在工作量很大的时候。医疗保健专业人员专注于患者护理的单一方面的“隧道视野”，就是意识降低的一个例子，这可能对安全有害。与航空和其他高风险组织一样，如果个人或更广泛的团队没有意识到情境意识的降低，可能会导致严重或潜在的致命后果。因此，我们概述了情境意识，并说明它是如何容易降低的。我们还提出了一些简单但有效的方法来提高它，进而提高患者安全。我们强调临床团队相互留意的重要性，特别是在手术室。
