Eden S H, Wood S M, Ptak K M
J Am Diet Assoc. 1987 Apr;87(4):492-5.
For many years, industry has utilized the concept of human error rates to monitor and minimize human errors in the production process. A consistent quality-controlled product increases consumer satisfaction and repeat purchase of product. Administrative dietitians have applied the concepts of using human error rates (the number of errors divided by the number of opportunities for error) at four hospitals, with a total bed capacity of 788, within a tertiary-care medical center. Human error rate was used to monitor and evaluate trayline employee performance and to evaluate layout and tasks of trayline stations, in addition to evaluating employees in patient service areas. Long-term employees initially opposed the error rate system with some hostility and resentment, while newer employees accepted the system. All employees now believe that the constant feedback given by supervisors enhances their self-esteem and productivity. Employee error rates are monitored daily and are used to counsel employees when necessary; they are also utilized during annual performance evaluation. Average daily error rates for a facility staffed by new employees decreased from 7% to an acceptable 3%. In a facility staffed by long-term employees, the error rate increased, reflecting improper error documentation. Patient satisfaction surveys reveal satisfaction, for tray accuracy increased from 88% to 92% in the facility staffed by long-term employees and has remained above the 90% standard in the facility staffed by new employees.
多年来，工业界一直运用人为差错率的概念来监控并尽量减少生产过程中的人为差错。质量稳定可控的产品能提高消费者满意度以及产品的复购率。行政营养师在一家三级医疗中心内的四家医院（总床位为788张）应用了人为差错率（差错数量除以出错机会数量）的概念。人为差错率被用于监控和评估配餐流水线员工的表现、评估配餐流水线工作站的布局和任务，此外还用于评估患者服务区域的员工。长期员工最初对差错率系统有些抵触和怨恨，而新员工则接受了该系统。现在所有员工都认为主管提供的持续反馈增强了他们的自尊和工作效率。员工差错率每天都会被监控，必要时用于指导员工；它们还在年度绩效评估中使用。新员工组成的机构的日均差错率从7%降至可接受的3%。在长期员工组成的机构中，差错率上升，这反映了差错记录不当。患者满意度调查显示，长期员工组成的机构中，配餐准确性的满意度从88%提高到了92%，而新员工组成的机构则一直保持在90%以上的标准。
