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摆脱指责文化:管理医疗差错的前进之路。

Moving Away from the Blame Culture: The Way Forward to Manage Medical Errors.

作者信息

Yusof Aimi Nadia Mohd, Razali Hazdalila Yais Haji

机构信息

Department of Medical Ethics and Law, Faculty of Medicine, Universiti Teknologi MARA, Sungai Buloh Campus, Sungai Buloh, Selangor, Malaysia.

出版信息

Malays J Med Sci. 2024 Dec;31(6):126-132. doi: 10.21315/mjms2024.31.6.10. Epub 2024 Dec 31.

DOI:10.21315/mjms2024.31.6.10
PMID:39830101
原文链接:https://pmc.ncbi.nlm.nih.gov/articles/PMC11740813/
Abstract

When a medical error occurs, the instinct to blame healthcare professionals may seems like a way to ensure they learn from their mistakes. However, in today's healthcare landscape, the blame culture, coupled with the fear of litigation, proves detrimental to improving patient care. This culture fosters a reluctance among healthcare professionals to openly disclose mistakes, depriving them of valuable learning opportunities. These professionals, often referred to as second victims, deserve as much attention and support as the patients who are affected by the errors. Given that medical errors are inevitable, it becomes imperative to effectively manage the aftermath to ensure all parties involved are adequately supported and shielded from adverse consequences. This article delves into the ethical complexities of medical errors, advocating for a shift from a blame-centric culture to one that prioritises support for second victims. The aim of this article is to underscore the crucial importance of addressing medical errors within the healthcare sector by fostering an environment that promotes learning and growth post-error.

摘要

当医疗差错发生时,指责医护人员的本能反应似乎是确保他们从错误中吸取教训的一种方式。然而,在当今的医疗环境中,指责文化加上对诉讼的恐惧,已被证明对改善患者护理有害。这种文化助长了医护人员不愿公开披露错误的心理,使他们失去了宝贵的学习机会。这些通常被称为“二次受害者”的专业人员,理应得到与受错误影响的患者同样多的关注和支持。鉴于医疗差错不可避免,有效处理后续事宜以确保所有相关方都能得到充分支持并免受不利后果的影响就变得至关重要。本文深入探讨了医疗差错的伦理复杂性,主张从以指责为中心的文化转向优先支持二次受害者的文化。本文的目的是强调通过营造一个促进差错后学习和成长的环境来解决医疗行业内医疗差错问题的至关重要性。

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本文引用的文献

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A recent two-fold increase in medical adverse event deaths among US inpatients.美国住院患者医疗不良事件死亡人数最近增加了两倍。
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Perfectionism as a predictor of physician burnout.完美主义是医生倦怠的预测指标。
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Suffering in Silence: Medical Error and its Impact on Health Care Providers.默默承受:医疗差错及其对医疗服务提供者的影响。
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A Just Culture Approach to Managing Medication Errors.一种管理用药错误的公正文化方法。
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The intention to disclose medical errors among doctors in a referral hospital in North Malaysia.马来西亚北部一家转诊医院的医生披露医疗差错的意愿。
BMC Med Ethics. 2017 Jan 23;18(1):3. doi: 10.1186/s12910-016-0161-x.
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Burnout and health behaviors in health professionals from seven European countries.来自七个欧洲国家的卫生专业人员的职业倦怠与健康行为
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WHO Efforts to Promote Reporting of Adverse Events and Global Learning.世界卫生组织促进不良事件报告及全球学习的努力。
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