Nuffield Department of Surgical Sciences, University of Oxford, UK; Human Factors Everywhere Ltd., UK.
Nuffield Department of Surgical Sciences, University of Oxford, UK; Maimonides Medical Center, Brooklyn, NY, USA.
Appl Ergon. 2022 Jan;98:103608. doi: 10.1016/j.apergo.2021.103608. Epub 2021 Oct 14.
Failure to rescue (FTR) denotes mortality from post-operative complications after surgery with curative intent. High-volume, low-mortality units have similar complication rates to others, but have lower FTR rates. Effective response to the deteriorating post-operative patient is therefore critical to reducing surgical mortality. Resilience Engineering might afford a useful perspective for studying how the management of deterioration usually succeeds and how resilience can be strengthened.
We studied the response to the deteriorating patient following emergency abdominal surgery in a large surgical emergency unit, using the Functional Resonance Analysis Method (FRAM). FRAM focuses on the conflicts and trade-offs inherent in the process of response, and how staff adapt to them, rather than on identifying and eliminating error. 31 semi-structured interviews and two workshops were used to construct a model of the response system from which conclusions could be drawn about possible ways to strengthen system resilience.
The model identified 23 functions, grouped into five clusters, and their respective variability. The FRAM analysis highlighted trade-offs and conflicts which affected decisions over timing, as well as strategies used by staff to cope with these underlying tensions. Suggestions for improving system resilience centred on improving team communication, organisational learning and relationships, rather than identifying and fixing specific system faults.
FRAM can be used for analysing surgical work systems in order to identify recommendations focused on strengthening organisational resilience. Its potential value should be explored by empirical evaluation of its use in systems improvement.
术后并发症导致有治愈意图的手术后死亡称为抢救失败（FTR）。高容量、低死亡率单位与其他单位具有相似的并发症发生率，但 FTR 率较低。因此，有效应对术后恶化的患者对于降低手术死亡率至关重要。韧性工程可能为研究恶化管理通常如何成功以及如何加强韧性提供有用的视角。
我们使用功能共振分析方法（FRAM）研究了在一个大型外科急救单位中，紧急腹部手术后对恶化患者的反应。FRAM 侧重于反应过程中固有的冲突和权衡，以及员工如何适应这些冲突和权衡，而不是识别和消除错误。我们进行了 31 次半结构化访谈和两次研讨会，构建了一个反应系统模型，从中可以得出关于可能的加强系统韧性的方法的结论。
该模型确定了 23 个功能，分为五个集群及其各自的可变性。FRAM 分析强调了影响时间安排的权衡和冲突，以及员工用来应对这些潜在紧张局势的策略。改善系统韧性的建议集中在改善团队沟通、组织学习和关系上，而不是识别和修复特定的系统故障。
FRAM 可用于分析外科工作系统，以确定侧重于加强组织韧性的建议。应通过实证评估其在系统改进中的使用来探索其潜在价值。
