Ladell Meagan M, Jacobson Nancy L, Yale Sarah C, McDermott Katie L, Papautsky Elizabeth L, Catchpole Kenneth R, Scanlon Matthew C
Medical College of Wisconsin, Milwaukee, Wisconsin, USA.
University of Illinois-Chicago, Chicago, Illinois, USA.
Acad Emerg Med. 2025 Mar;32(3):340-347. doi: 10.1111/acem.15076. Epub 2025 Mar 3.
Investigating error in healthcare has long been a central focus of patient safety efforts, yet this approach oversimplifies the complexities of a deeply interconnected and dynamic system. This paper argues that framing patient harm solely as "error" has failed to yield meaningful improvements, as it overlooks the broader factors contributing to adverse outcomes. Through a case study, we illustrate how an exclusive focus on error investigation missed critical insights and propose that attention should instead be directed towards identifying and managing hazards. Emphasizing the importance of treating healthcare as a sociotechnical system, we argue for the application of sociotechnical system thinking, particularly in addressing diagnostic errors in high-pressure environments like emergency medicine. The traditional methods, such as root cause analysis, error investigation, and the Swiss cheese model, are no longer sufficient. These outdated frameworks fail to address the systemic challenges clinicians face and often misguide safety interventions. The paper calls for a paradigm shift towards re-designing healthcare systems using human factors research to better align with the complexities of clinical work and the hazards that lead to harm.
长期以来,调查医疗保健中的差错一直是患者安全工作的核心重点,但这种方法过于简化了一个深度互联且动态的系统的复杂性。本文认为,仅将患者伤害归结为“差错”未能带来有意义的改善,因为它忽视了导致不良后果的更广泛因素。通过一个案例研究,我们说明了单纯关注差错调查是如何错过关键见解的,并建议应转而将注意力导向识别和管理危险因素。强调将医疗保健视为一个社会技术系统的重要性,我们主张应用社会技术系统思维,尤其是在应对像急诊医学这样的高压环境中的诊断差错时。诸如根本原因分析、差错调查和瑞士奶酪模型等传统方法已不再足够。这些过时的框架无法应对临床医生面临的系统性挑战,并且常常误导安全干预措施。本文呼吁进行范式转变,利用人因研究重新设计医疗系统,使其更好地适应临床工作的复杂性以及导致伤害的危险因素。