超越错误:对严重不良事件中人为因素的定性研究
Chenjerai Mujuru1, Carmelle Peisah2,3
1Western Sydney Local Health District, Sydney, Australia.
概括
医疗保健质量和安全方面的人类因素不仅仅是错误. 关系和系统问题,包括临床医生的态度和沟通,显著导致患者不良事件,需要更广泛的干预.
科学领域:
- 医疗保健的质量和安全
- 人类因素研究研究
- 患者安全 患者安全
背景情况:
- 医疗保健中的传统人类因素研究往往只关注个人错误 (认知/基于知识).
- 这种有限的观点忽略了导致患者不良事件的关键关系和系统因素.
- 了解这些更广泛的影响对于改善医疗保健质量至关重要.
研究的目的:
- 探索导致严重患者不良事件的关系性和系统性人类因素.
- 调查共享的临床医生态度和行为在患者安全中的作用.
- 在公共卫生环境中识别个人错误以外的因素.
主要方法:
- 重症不良事件审查 (SAER) 的后续定性多事件内容分析.
- 这项研究是在澳大利亚新南威尔士州的一个大都市当地卫生区进行的.
- 通过20份SAER报告 (2022-2023) 实现了数据和.
主要成果:
- 只有35%的严重不良事件主要是基于错误的.
- 关键的新兴主题包括延迟/惯性 (包括年龄歧视),"一切或没有"终身护理,沟通缺陷和实施差距.
- 研究样本主要包括不同专业的老年男性患者 (平均年龄69岁).
结论:
- 在不良事件中,人为因素不仅包括认知或基于知识的错误.
- 在纠正错误的同时,解决临床态度,行为和关系至关重要.
- 需要采取"软措施"来改善复杂的医疗环境中的患者安全.
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