Rigamonti Daniele, Rigamonti Karen H
Neurological Surgery, Johns Hopkins Medicine International, Johns Hopkins Health System Corporation, Baltimore, USA.
Medicine, Johns Hopkins Medicine International, Johns Hopkins Health System Corporation, Baltimore, USA.
Cureus. 2021 Feb 7;13(2):e13192. doi: 10.7759/cureus.13192.
In 2000, "To Err Is Human" brought to light the fact that the estimated number of people dying from medical errors occurring in hospitals exceeded those that die from motor vehicle accidents (MVAs), breast cancer, or acquired immunodeficiency syndrome (AIDS) - three causes receiving far more public attention. The report prompted the gradual adoption of safety processes developed in the nuclear and aviation industries. However, sophisticated engineering solutions to operations are not enough. High and low mortality hospitals have similar processes and procedures, but low-mortality hospitals are more proficient at recognizing and managing serious complications as they unfold. This ability to rescue a deteriorating situation (resilience) reflects a healthier safety culture. Organizations move within the safety space in the direction of either more or less resilience depending on the fluctuation of their safety culture. Improving resilience requires transforming learned safety practices into a "habit" in conjunction with accepting accountability. Personal accountability means commitment to safe practices along with effective and transparent reporting of near misses/close calls and adverse events (AEs). Institutional accountability means putting safety first by ensuring the availability of appropriate resources, role leadership modeling, and effective management of sentinel events (SEs) to reduce harm occurrence and re-occurrence. This requires a more robust root cause analysis (RCA) process to guarantee that action plans produce strong and effective corrective measures. Synergistic coaching interventions include instilling the awareness that failure can and will happen, mapping team talents, and assessing gaps. These interventions will optimize group expertise, reaffirming the concept of institutional and personal accountability. The unending performance of drills will sustain the group resilience under both expected and unexpected conditions. Given the strong correlation between practice environment and outcomes, sustained improvement of the safety climate will produce more robust safety behaviors and ultimately better outcomes.
2000年，《人皆会犯错》揭示了一个事实，即据估计，因医院医疗差错而死亡的人数超过了死于机动车事故、乳腺癌或获得性免疫缺陷综合征（艾滋病）的人数——后三种死因受到公众更多关注。该报告促使医院逐渐采用核工业和航空业所开发的安全流程。然而，仅靠复杂的工程解决方案来应对医疗操作是不够的。死亡率高和低的医院有着相似的流程和程序，但低死亡率医院在严重并发症出现时更善于识别和处理。这种挽救恶化局面的能力（恢复力）反映了一种更健康的安全文化。组织在安全空间内朝着恢复力增强或减弱方向发展，这取决于其安全文化的波动。提高恢复力需要将所学的安全做法转化为一种“习惯”，同时接受问责。个人问责意味着致力于安全做法，并对未遂事件/险情和不良事件（AE）进行有效且透明的报告。机构问责意味着将安全放在首位，确保提供适当资源、发挥领导表率作用，并对警示事件（SE）进行有效管理，以减少伤害的发生和再次发生。这需要一个更强大的根本原因分析（RCA）流程，以确保行动计划能产生有力且有效的纠正措施。协同指导干预措施包括灌输失败可能且将会发生的意识、梳理团队才能以及评估差距。这些干预措施将优化团队专业技能，重申机构和个人问责的理念。持续进行演练将在预期和意外情况下维持团队的恢复力。鉴于实践环境与结果之间存在密切关联，持续改善安全氛围将产生更有力的安全行为，最终带来更好的结果。
