Hardie J A, Oeppen R S, Shaw G, Holden C, Tayler N, Brennan P A
Trauma & Orthopaedic Department, Frimley Park Hospital, Camberley, GU16 7UJ, UK.
Department of Clinical Radiology, University Hospitals Southampton, SO16 6YD, UK.
Br J Oral Maxillofac Surg. 2020 Nov;58(9):1073-1077. doi: 10.1016/j.bjoms.2020.08.104. Epub 2020 Aug 27.
High-risk organisations (HRO), including aviation, undergo formal communication training, with emphasis on safety-critical moments. Such training is not widespread or mandatory in healthcare, and while there are many differences both share the 'human element' with circumstances leading to an increased risk of harm. A typical operating theatre consists of an operating surgeon, and an assisting surgeon, roles that may change throughout the course of a procedure. Similarly, a training aircraft or multi-crew cockpit (flight deck) has a pilot in control, or 'pilot flying', and a 'pilot not flying'. Both interact with wider teams, for example the scrub team and air traffic controllers, respectively. Surgical error is the second most prevalent cause of preventable harm to patients after drug errors. Every year in the UK National Health Service (NHS), there are typically 500 never events, 21,000 serious incidents, and many more episodes of physical or psychological harm. Ineffective communication (46%) is the most common behavioural factor leading to a never event. In this review, we examine the concept of 'sterile cockpit', use of unambiguous terminology, callsigns, important information readback, sharing of mental models, and the mini-brief, and how these may be used to reduce patient harm during safety-critical moments.
包括航空业在内的高风险组织(HRO)会接受正式的沟通培训,重点是安全关键时刻。此类培训在医疗保健领域并不普遍,也不是强制性的,尽管两者存在许多差异,但在导致伤害风险增加的情况下都存在“人为因素”。一个典型的手术室由一名主刀外科医生和一名助手组成,这些角色在手术过程中可能会发生变化。同样,一架训练用飞机或多机组驾驶舱(驾驶舱)有一名负责操控的飞行员,即“操控飞行员”,以及一名“非操控飞行员”。两者分别与更广泛的团队互动,例如刷手团队和空中交通管制员。手术失误是继用药失误之后导致患者可预防伤害的第二大常见原因。在英国国民医疗服务体系(NHS)中,每年通常会发生500起严重可避免事件、21000起严重事故,以及更多身体或心理伤害事件。无效沟通(46%)是导致严重可避免事件的最常见行为因素。在本综述中,我们探讨了“无菌驾驶舱”的概念、明确术语的使用、呼号、重要信息复述、心理模型共享以及简短预沟通,以及这些如何用于在安全关键时刻减少患者伤害。