Arnal-Velasco Daniel, Heras-Hernando Violeta
Unit of Anesthesiology and Reanimation, Hospital Universitario Fundacion Alcorcon, Alcorcon, Spain.
Curr Opin Anaesthesiol. 2023 Jun 1;36(3):376-381. doi: 10.1097/ACO.0000000000001257. Epub 2023 Feb 8.
Learning from errors has been the main objective of patient safety initiatives for the last decades. The different tools have played a role in the evolution of the safety culture to a nonpunitive system-centered one. The model has shown its limits, and resilience and learning from success have been advocated as the key strategies to deal with healthcare complexity. We intend to review the recent experiences in applying these to learn about patient safety.
Since the publication of the theoretical basis for resilient healthcare and Safety-II, there is a growing experience applying these concepts into reporting systems, safety huddles, and simulation training, as well as applying tools to detect discrepancies between the intended work as imagined when designing the procedures and the work as done when front-line healthcare providers face the real-life conditions.
As part of the evolution in patient safety science, learning from errors has its function to open the mindset for the next step: implementing learning strategies beyond the error. The tools for it are ready to be adopted.
在过去几十年中，从错误中学习一直是患者安全倡议的主要目标。不同的工具在安全文化向以系统为中心的非惩罚性体系的演变过程中发挥了作用。该模式已显示出其局限性，而恢复力和从成功中学习已被倡导为应对医疗复杂性的关键策略。我们打算回顾近期应用这些策略来了解患者安全的经验。
自从弹性医疗保健和安全-II的理论基础发表以来，将这些概念应用于报告系统、安全碰头会和模拟培训，以及应用工具来检测设计程序时设想的预期工作与一线医疗服务提供者面对现实生活情况时实际完成的工作之间的差异，这方面的经验越来越多。
作为患者安全科学发展的一部分，从错误中学习的作用是为下一步打开思维：实施超越错误的学习策略。相关工具已可供采用。
