醫(yī)療安全文化

醫(yī)療安全文化WHY?Inlow-techarea...However,newertechnologydoesn’teliminateerrorNordoesevennewertechnology話說(shuō)

C.R.M.北城、崇愛(2002)醫(yī)療疏失後，林(2003)以航空人因工程理論追蹤病患風(fēng)險(xiǎn)因素。風(fēng)險(xiǎn)構(gòu)面依序急診核心醫(yī)護(hù)人員能力醫(yī)護(hù)人員與家屬及病患溝通醫(yī)護(hù)人員之間溝通醫(yī)護(hù)人員與軟體系統(tǒng)互動(dòng)醫(yī)護(hù)人員與硬體設(shè)備互動(dòng)醫(yī)護(hù)人員與環(huán)境互動(dòng)重要因素依序急診醫(yī)師專科知識(shí)缺乏醫(yī)師與病患及家屬溝通不良急診主治醫(yī)師人力缺乏醫(yī)護(hù)人員醫(yī)療疏失風(fēng)險(xiǎn)認(rèn)知缺乏排班型態(tài)不合理醫(yī)療糾紛發(fā)生比例較高的地方急診室手術(shù)室加護(hù)病房

(吳，2002)

WhatisCRM?Usingalltheavailableresources–information,equipment,andpeople–toachievesafeandefficientflightoperations〞JohnLauber(1977)WhatisCRMTraining?

CRMtrainingprovidesasetofcountermeasuresagainsthumanerror;itisbasedonthepremisethathumanerrorisubiquitousandinevitable.(透過訓(xùn)練杜絕以往認(rèn)為是不可防止、比比皆是的人為疏失)Dr.Helmreich(1996)AVIATIONvs.MEDICINE當(dāng)白袍映上藍(lán)天…

Sodifferent,yetsosimilarDetroitNewsandFreePress.Sunday,February6,2000.RANDStudy:QualityofHealth

CareOftenNotOptimalPatients’careoftendeficient,studysays.Propertreatmentgivenhalfthetime.Onaverage,doctorsprovideappropriatehealthcareonlyhalfthetime,alandmarkstudyofadultsin12U.S.metropolitanareassuggests.MedicalCareOftenNotOptimalFailuretoTreatPatientsFullySpansRangeofWhatIsExpectedofPhysiciansandNursesStudy:U.S.Doctorsarenotfollowingtheguidelinesforordinaryillnesses.TheAmericanhealthcaresystem,oftentoutedasacutting-edgeleaderintheworld,suddenlyfindsitselfmiredinseriousquestionsabouttheabilityofitshospitalsanddoctorstodeliverqualitycaretomillions.Medicalerrorscorrodequalityofhealthcaresystem就醫(yī)自保完全手冊(cè)第一章：臺(tái)灣的醫(yī)療疏失第二章：如何找對(duì)醫(yī)師…醫(yī)療有所謂的不確定性，開錯(cuò)刀時(shí)有所聞，不管醫(yī)師替你安排任何手術(shù)，你都要學(xué)會(huì)「問清楚」，醫(yī)師則必須「說(shuō)明白」；不清不楚、不明不白的手術(shù)，千萬(wàn)別做。手術(shù)前「三思八問」三思而後行，八問而後動(dòng)YOUMAKEERRORS!Tomakepeoplechange…HumanErrorTypeH1-ActiveFailure-(Aware)Nonadherencetostandardsandprocedures明知故犯H2-PassiveFailure-(Unaware)breakdownofcoordination,misunderstanding,communicationfailures,lackofexpectedsupport無(wú)心之過H3-ProficiencyFailureInappropriatehandlingofitssystems力有未逮H4–Incapacitationphysicalorpsychologicalinability失能H1-ActiveFailure

明知故犯(Aware)

Nonadherencetostandardsandprocedures-thiscanincludenonadherencetoSOP,lawviolations,failuretofollowwritteninstructions,failuretomanagecockpitresources,grosslackofappropriatevigilance,laziness.H2-PassiveFailure

無(wú)心之過(Unaware) Unawareness-thiscanincludebreakdownofcoordination,misunderstanding,communicationfailures,lackofexpectedsupport,-itcanbeexacerbatedbyhighworkload,distraction,complacency,forgetfulness,boredom,lowarousallevel.

Inappropriatehandlingofaircraftoritssystems-thiscanincludemisjudgment,makinganincorrectdecision-itcanbeexacerbatedbylackofexperience,lackoftrainingorsimpleincompetence.H3 -ProficiencyFailure

力有未逮H4–Incapacitation

失能

Flightcrewmemberunabletoperformhis/herdutyduetophysicalorpsychologicalinability.SAFETYCULTURE

Itisthemindset&commitment

topursuitsafety,whichrequiresnonstopefforts.(心態(tài)、承諾、契而不捨的追蹤)Tomakepeoplechange,whatweneedis…CultureDefinitionsUsuallybaseduponablendofvisionaryideas,corporatecultureappearstoreflectsharedbehaviors,beliefs,attitudesandvaluesregardingorganisationalgoals,functionsandprocedureswhichareseentocharacteriseparticularorganisationsFurnham,A.,Gunter,B.,1993.CorporateAssessment.Routledge,London.CultureandSafetyAccordingtotheInstituteofMedicine(IOM),thebiggestchallengetomovingtowardasaferhealthsystemischangingtheculturefromoneofblamingindividualsforerrorstooneinwhicherrorsaretreatednotaspersonalfailures,butopportunitiestoimprovethesystemandpreventharmASafetyCultureis……Constantawarenessofpotentialforthingstogowrong(持續(xù)監(jiān)察潛在性問題進(jìn)展為錯(cuò)誤)Culturethatisopenandfair(文化是開放和公平的)Culturethatencouragespeopletospeakupaboutmistakes(文化是讓人有有勇氣說(shuō)出錯(cuò)誤)Abletolearnaboutwhatiswrongandthenputthingsright(是爲(wèi)了學(xué)習(xí)作對(duì)的事)

NPSA病態(tài)期只要不被抓到誰(shuí)在乎資訊反應(yīng)期平安很重要只要出問題一定處理管理期具備危害管理的機(jī)制活化期平安是我的責(zé)任主動(dòng)處理問題新生期平安是組織的一局部員工主動(dòng)參與信任病人平安文化的演進(jìn)〔石崇良，2005〕1987年-2006年底，醫(yī)事審議委員20年來(lái)共完成5381份醫(yī)療訴訟鑑定報(bào)告，最後有11％﹙約590多案﹚被鑑定為醫(yī)事人員有疏失，6％為可能有疏失，而醫(yī)事人員大部份是醫(yī)師。其中外科佔(zhàn)34％最多、內(nèi)科近30％、婦產(chǎn)科15％。5000多宗醫(yī)療訴訟案中，有60％病人死亡，重傷害有25％。

資料來(lái)源：2007年11月19日蘋果日?qǐng)?bào)國(guó)內(nèi)統(tǒng)計(jì)SwissCheeseModel

Ifallthebarriersarefailed..

providerspatientsProcedurepolicyAccidentPeripheralsproductsThetruthis…..↗醫(yī)療事件錯(cuò)誤事件是一連串疏失所造成↗多半的醫(yī)療不良事件並非個(gè)人疏忽或缺乏訓(xùn)練↗75％的醫(yī)療問題來(lái)自系統(tǒng)的錯(cuò)誤providerspatientsProcedurepolicyPeripheralsproductsLatentfailuresActivefailures

Stoptheerror!defences,barriersandsafeguardsPatientSafety:LeadershipRoleOursystemsaretoocomplextoexpectmerelyextraordinarypeopletoperformperfectly100percentofthetime.Weasleadershavearesponsibilitytoputinplacesystemstosupportsafepractice.〞*.90X.90X.90X.90=.65or65%**LeadershipGuidetoPatientSafety,InstituteforHealthcareImprovement,2005

醫(yī)療異常事件醫(yī)療錯(cuò)誤(Medicalerror)醫(yī)療不良事件(Medicaladverseevent)

警訊事件(Sentinelevent)

醫(yī)策會(huì)2005醫(yī)療不良事件﹙MedicalAdverseEvents﹚傷害事件並非導(dǎo)因於原有的疾病本身，而是由於醫(yī)療行為造成病人身體受到傷害、住院時(shí)間延長(zhǎng)，或在離院時(shí)仍帶有某種程度的失能、甚至死亡。醫(yī)策會(huì)2005醫(yī)療體系組織架構(gòu)法律約束醫(yī)療環(huán)境工作性質(zhì)工作流程作業(yè)標(biāo)準(zhǔn)檢核制度醫(yī)院管理財(cái)務(wù)限制平安文化品質(zhì)管控工作環(huán)境工作負(fù)擔(dān)人力配置設(shè)備維護(hù)行政支援團(tuán)隊(duì)因素溝通不良領(lǐng)導(dǎo)統(tǒng)馭監(jiān)督指導(dǎo)病人因素複雜嚴(yán)重度溝通能力社會(huì)條件個(gè)人喜好個(gè)人因素知識(shí)缺乏技術(shù)不熟練身體心智狀態(tài)醫(yī)療不良事件

PatientSafetyis

NoAccident

TPR

(Taiwanpatientsafetyreportingsystem)「臺(tái)灣病人平安通報(bào)系統(tǒng)」以匿名,自願(yuàn),保密,不究責(zé),共同學(xué)習(xí)五大宗旨為出發(fā)點(diǎn)。收集多方的病人平安相關(guān)經(jīng)驗(yàn)，進(jìn)行趨勢(shì)分析並對(duì)醫(yī)療機(jī)構(gòu)提出警示訊息及學(xué)習(xí)案例。建立機(jī)構(gòu)間經(jīng)驗(yàn)分享以及資訊交流之平臺(tái)，進(jìn)一步營(yíng)造平安之就醫(yī)環(huán)境。2021醫(yī)療品質(zhì)及病人平安工作目標(biāo)目標(biāo)一：提升用藥平安目標(biāo)二：落實(shí)醫(yī)療機(jī)構(gòu)感染控制目標(biāo)三：提升手術(shù)平安目標(biāo)四：預(yù)防病人跌倒及降低傷害程度目標(biāo)五：鼓勵(lì)異常事件通報(bào)資料正確性目標(biāo)六：提升醫(yī)療照顧人員間溝通的有效性目標(biāo)七：鼓勵(lì)病人及其家屬參與病人平安工作目標(biāo)八：提升管路平安目標(biāo)九：消防平安CreatingaCultureofSafety如何提昇平安文化﹙四要素﹚Reportingculture建立信任的機(jī)制Justiceculture懲罰與歸責(zé)的拿捏Flexibleculture面對(duì)改變能及時(shí)與有效的應(yīng)對(duì)Learningculture觀察、反應(yīng)與分析、創(chuàng)新、行動(dòng)

Source:JamesReason,managingtheriskoforganizationalaccidents

Safety–ComprisedofManyPiecesReportEducateInformAnalyzeTrustSafety–PuttingitAllTogetherReportEducateInformAnalyzeTrus