Wiig Siri, Braithwaite Jeffrey, Clay-Williams Robyn
SHARE-Centre for Resilience in Healthcare, University of Stavanger, Kjell Arholms gate 41, 4036 Stavanger, Norway.
Australian Institute of Health Innovation, Macquarie University, Balaclava Rd, 2109 Sydney, Australia.
Int J Qual Health Care. 2020 Jun 4;32(4):281-284. doi: 10.1093/intqhc/mzaa013.
Accident models and theoretical foundations underpinning safety investigations are key to understanding how investigators construct causality and make recommendations. Safety science has devoted large efforts to investigating and theorizing about accidents. Why doesn't healthcare pay more interest to these theories when investigating healthcare accidents? We use established accident theories to suggest how these can support safety investigations in healthcare and provide new lenses to investigatory bodies. We reflect on examples from research and practice in healthcare systems and other high-risk industries. Investigation processes and reports serve multiple purposes. We argue there is an untapped improvement potential for healthcare safety investigations and suggest new ways of integrating different accident theoretical reflections with investigatory practice.
支撑安全调查的事故模型和理论基础是理解调查人员如何构建因果关系并提出建议的关键。安全科学在事故调查和理论化方面投入了大量精力。为什么医疗保健行业在调查医疗事故时对这些理论没有给予更多关注呢?我们运用已有的事故理论来探讨其如何支持医疗保健领域的安全调查,并为调查机构提供新的视角。我们思考了医疗系统和其他高风险行业的研究与实践中的例子。调查过程和报告具有多种目的。我们认为医疗安全调查存在尚未挖掘的改进潜力,并提出将不同事故理论思考与调查实践相结合的新方法。