Short T G, O'Regan A, Jayasuriya J P, Rowbottom M, Buckley T A, Oh T E
Department of Anaesthesia and Intensive Care, Chinese University of Hong Kong, Shatin.
Anaesthesia. 1996 Jul;51(7):615-21. doi: 10.1111/j.1365-2044.1996.tb07841.x.
The rôle of an anaesthetic incident reporting programme in improving anaesthetic safety was studied. The programme had been running for 4 to 5 years in three large hospitals in Hong Kong and more than 1000 incidents have been reported. The number of reports being made and frequency of the various categories of incident reported, did not alter during the study period. Sixty nine percent of incidents were considered to be preventable. Human error contributed to 76% of incidents and violations of standard practice to 30% of incidents. The programme was effective in its ability to detect latent errors in the anaesthesia system and when these were corrected, incidents did not recur. The frequency with which various contributing factors were cited did not decrease with time. With the exception of problems dealt with by specific protocol development, the study found no evidence that an increasing awareness of the problem of human error was effective in reducing this kind of problem.
研究了麻醉事件报告程序在提高麻醉安全性方面的作用。该程序已在香港的三家大型医院运行了4至5年，已报告了1000多起事件。在研究期间，报告的数量和各类事件报告的频率没有改变。69%的事件被认为是可以预防的。人为失误导致了76%的事件，违反标准操作导致了30%的事件。该程序在检测麻醉系统中的潜在错误方面很有效，当这些错误得到纠正后，事件就不会再次发生。各种促成因素被提及的频率并没有随着时间的推移而降低。除了通过制定特定协议处理的问题外，该研究没有发现证据表明对人为失误问题认识的提高能有效减少这类问题。
