医疗疏失扩散模型

编辑链接
维基百科，自由的百科全书

医疗疏失扩散模型（英语：healthcare error proliferation model，简称HEPM）是英国曼彻斯特大学教授詹姆斯·瑞森（James Reason）所发表的瑞士奶酪模型的改编版本，用来说明：1. 现代医疗系统固有的复杂性，以及2. 这些系统里面人为错误的归因。HEPM[1]解释疏失发生的原因和会导致的不良后果的事件序列。这个模型强调组织上和外部的文化在识别、预防、缓解、和防御措施所能发挥的作用。

简介

医疗系统之所以复杂，是因为它们在结构（例如护理单位、药房、急诊室、手术室），还有专业（例如护理人员、医生、药剂师、行政管理人员、治疗师）之上种类繁多，而关联的要素之间能够相互适应，并能从经验中学习，以及改变。“复杂适应系统”（CAS）这个名词是由在跨学科的圣菲研究所（SFI）的约翰·霍兰德和默里·盖尔曼两位学者所提出。随后，露丝·安德森（Ruth A. Anderson）、鲁宾·麦克丹尼尔（Rubin McDaniels）、和保罗·西里尔斯（英语：Paul Cilliers）等学者把CAS的理论和研究扩展，纳入社会科学（例如教育和医疗卫生）之中运用，。

模型概述

HEPM把瑞士奶酪模型[2]理论用到具有复杂性质的医疗系统和集成架构之上。瑞士奶酪模型把复杂，而能自我适应的系统与多孔的瑞士奶酪切片相提并论。[2][3]切好的奶酪片被称为防御层，用来表达这些切片在系统中的作用和功能，而这些作用和功能具有拦截和防止危险的能力。这些防御层代表离散的位置或是组织级别，而这些位置或组织级别可能本身具有错误，并让错误发展。保护层的功能包含四种：1）组织领导能力，2）风险监督，3）不安全做法的情况，以及4）不安全执行后的结果。

HEPM把医院描述为具有多个防御层，配备有维持关键防御工事所需的基本要素[4]。透过检查防御层的属性，潜在的故障点，可显示疏失发生的原因[5]。专家们讨论在CAS中对这些保护层的重要性作检查[6][7]，也把临床医生的心理安全列入考虑。这个HEPM把詹姆斯·瑞森的开创性理论更加扩展。

这个模型把CAS当作一种关键特性。这种复杂的系统有独特的自我组织能力，同时透过非线性关系发挥相互作用[8][9]，其中专业人员充当信息处理者[10][11]并与环境共同演进[12]。医疗卫生提供者在系统中扮演不同的角色，使用不同的方法来处理信息，以解决组织内和跨组织之间的整体性问题。[13]

定义

CAS是在一个医疗卫生提供机构中，同时有多种临床和行政代理人做非线性的交互行动，而其中的作业人员和患者是信息处理者，全部会与环境共同演进，达到安全可靠，以患者为中心的结果（英语：patient-centered outcomes）。[14]

参见

参考文献

  1. ^ Palmieri, P. A., DeLucia, P. R., Ott, T. E., Peterson, L. T., & Green, A. The anatomy and physiology of error in averse healthcare events. E. Ford; G. Savage (编). Advances in Health Care Management 7. Emerald Publishing Group. 2008: 33–68. doi:10.1016/S1474-8231(08)07003-1. 
  2. ^ 2.0 2.1 Reason, J. T. Human Error. Cambridge University Press. 1990. ISBN 0-521-31419-4. 
  3. ^ Reason, J. T. Human error: models and management. British Medical Journal. 2000, 320 (7237): 768–70. PMC 1117770 可免费查阅. PMID 10720363. doi:10.1136/bmj.320.7237.768. 
  4. ^ Cook, Richard I.; O’Connor, Michael F. Thinking about accidents and systems. January 2005 [6 May 2021]. （原始内容存档于2022-01-11）. 
  5. ^ Leape, L L; Bates, D W. Systems analysis of adverse drug events. ADE Prevention Study Group. JAMA. 5 July 1995 [6 May 2021]. （原始内容存档于2022-01-10）. 
  6. ^ Kohn, Linda T.; Corrigan, Janet M. To Err is Human: Building a Safer Health System. [6 May 2021]. doi:10.17226/9728. （原始内容存档于2022-06-09）. 
  7. ^ Wiegmann, Douglas A; Shappell, Scott. A human error approach to aviation accident analysis: The human factors analysis and classification system. January 2005 [6 May 2021]. （原始内容存档于2022-01-10）. 
  8. ^ Anderson, R. A., Issel, M. L., & McDaniel, R. R. Nursing Homes as Complex Adaptive Systems: Relationship between Management Practice and Resident Outcomes. Nursing Research. 2003, 52 (1): 12–21. PMC 1993902 可免费查阅. PMID 12552171. doi:10.1097/00006199-200301000-00003. 
  9. ^ Cilliers, P. Complexity and post modernism: Understanding complex systems. New York: Routledgel. 1998. ISBN 978-0-415-15286-0. 
  10. ^ Cilliers, Paul. Complexity and Postmodernism Understanding Complex Systems. Taylor & Francis eBooks. 12 February 1998 [2022-01-14]. （原始内容存档于2022-05-03）. 
  11. ^ Mcdaniel, Reuben R; Driebe, Dean J. Complexity Science and Health Care Management. September 2001 [6 May 2021]. doi:10.1016/S1474-8231(01)02021-3. （原始内容存档于2022-01-10）. 
  12. ^ Casti, John L. Computing the uncomputable. 7 December 1998 [6 May 2021]. （原始内容存档于2022-01-10）. 
  13. ^ Savage, Grant T.; Ford, Eric W. Patient Safety and Health Care Management. Emerald Group Publishing. : 46 [2022-01-14]. （原始内容存档于2022-01-10）. 
  14. ^ Palmieri, P. A., DeLucia, P. R., Ott, T. E., Peterson, L. T., & Green, A. The anatomy and physiology of error in averse healthcare events. Advances in Health Care Management. Advances in Health Care Management. 2008, 7: 33–68. ISBN 978-1-84663-954-8. doi:10.1016/S1474-8231(08)07003-1. 

参考

文章

  • Anderson, R. A., Issel, M. L., & McDaniel, R. R. (2003). Nursing homes as complex adaptive systems: Relationship between management practice and resident outcomes. Nursing Research, 52(1): 12-21.
  • Berta, W. B. & Baker, R. (2004). Factors that impact the transfer and retention of best practices for reducing error in hospitals. Health Care Management Review, 29(2): 90-97.
  • Chiles, J. R. (2002). Inviting disaster: Lessons from the edge of technology. New York: HarperCollins Publishers.
  • Coleman, H. J. (1999). What enables self-organizing behavior in business. Emergence, 1(1): 33-48.
  • Cook, R. I., Render, M., & Woods, D. D. (2000). Gaps in the continuity of care and progress on patient safety. British Medical Journal, 320(7237): 791-794.
  • Leape, L. L., Bates, D. W., Cullen, D. J., Cooper, J., Demonaco, H. J., Gallivan, T., R., H., Ives, J., Laird, N., Laffel, G., Nemeskal, R., Peterson, L. A., Porter, K., Servi, D., Shea, B. F., Small, S. D., Sweitzer, B. J., Thompson, B. T., & van der Vliet, M. (1995). Systems analysis of adverse drug events. ADE prevention study group. Journal of the American Medical Association, 274(1): 35-43.
  • Leape, L. L. & Berwick, D. M. (2005). Five years after "To err is human": What have we learned? Journal of the American Medical Association, 293(19): 2384-2390.
  • Leduc, P. A., Rash, C. E., & Manning, M. S. (2005). Human factors in UAV accidents, Special Operations Technology, Online edition ed., Vol. 3.
  • Leonard, M. L., Frankel, A., & Simmonds, T. (2004). Achieving safe and reliable healthcare: Strategies and solutions. Chicago: Health Administration Press.
  • Rasmussen, J. (1990). The role of error in organizing behavior. Ergonomics, 33: 1185-1199.
  • Rasmussen, J. (1999). The concept of human error: Is it useful for the design of safe systems in health care? In C. Vincent & B. deMoll (Eds.), Risk and safety in medicine: 31-47. London: Elsevier.
  • Reason, J. T. & Mycielska, K. (1982). Absent-minded? The psychology of mental lapses and everyday errors. Englewood Cliffs, NJ: Prentice-Hall Inc.
  • Reason, J. T. (1990). Human error. New York: Cambridge University Press.
  • Reason, J. T. (1997). Managing the risks of organizational accidents. Aldershot: Ashgate Publishing.
  • Reason, J. T. (1998). Managing the risks of organizational accidents. Aldershot, England: Ashgate.
  • Reason, J. T. (2000). Human error: Models and management. British Medical Journal, 320, 768-770.
  • Reason, J. T., Carthey, J., & de Leval, M. R. (2001). Diagnosing vulnerable system syndrome: An essential prerequisite to effective risk management. Quality in Health Care, 10(S2): 21-25.
  • Reason, J. T. & Hobbs, A. (2003). Managing maintenance error: A practical guide. Aldershot, England: Ashgate.
  • Roberts, K. (1990). Some characteristics of one type of high reliability organization. Organization Science, 1(2): 160-176.
  • Roberts, K. H. (2002). High reliability systems. Report on the institute of medicine committee on data standards for patient safety on September 23, 2003.

书籍

Cilliers, P. (1998) Complexity and post modernism: Understanding complex systems. New York: Routledge. (ISBN 978-0415152860)

其他文献

复杂理论

  • Holland, J. H. (1992). Adaptation in natural and artificial systems. Cambridge, MA: MIT Press. (ISBN 978-0262581110)
  • Holland, J. H. (1995). Hidden order: How adaptation builds complexity. Reading, MA: Helix Books. (ISBN 978-0201442304)
  • Holland, J. H. (1998). Emergence: From chaos to order. Reading, MA: Addison-Wesley. (ISBN 978-0738201429)
  • Waldrop, M. M. (1990). Complexity: The emerging science at the edge of order and chaos. New York: Simon & Schuster (ISBN 978-0671767891)
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