醫(yī)療安全文化

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

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)險因素。風(fēng)險構(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)互動醫(yī)護(hù)人員與硬體設(shè)備互動醫(yī)護(hù)人員與環(huán)境互動重要因素依序急診醫(yī)師專科知識缺乏醫(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)自保完全手冊第一章：臺灣的醫(yī)療疏失第二章：如何找對醫(yī)師…醫(yī)療有所謂的不確定性，開錯刀時有所聞，不管醫(yī)師替你安排任何手術(shù)，你都要學(xué)會「問清楚」，醫(yī)師則必須「說明白」；不清不楚、不明不白的手術(shù)，千萬別做。手術(shù)前「三思八問」三思而後行，八問而後動YOUMAKEERRORS!Tomakepeoplechange…HumanErrorTypeH1-ActiveFailure-(Aware)Nonadherencetostandardsandprocedures明知故犯H2-PassiveFailure-(Unaware)breakdownofcoordination,misunderstanding,communicationfailures,lackofexpectedsupport無心之過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)展為錯誤)Culturethatisopenandfair(文化是開放和公平的)Culturethatencouragespeopletospeakupaboutmistakes(文化是讓人有有勇氣說出錯誤)Abletolearnaboutwhatiswrongandthenputthingsright(是爲(wèi)了學(xué)習(xí)作對的事)

NPSA病態(tài)期只要不被抓到誰在乎資訊反應(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)任主動處理問題新生期平安是組織的一局部員工主動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年來共完成5381份醫(yī)療訴訟鑑定報告，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％。

資料來源：2007年11月19日蘋果日報國內(nèi)統(tǒng)計SwissCheeseModel

Ifallthebarriersarefailed..

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

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

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

警訊事件(Sentinelevent)

醫(yī)策會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、住院時間延長，或在離院時仍帶有某種程度的失能、甚至死亡。醫(yī)策會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)重度溝通能力社會條件個人喜好個人因素知識缺乏技術(shù)不熟練身體心智狀態(tài)醫(yī)療不良事件

PatientSafetyis

NoAccident

TPR

(Taiwanpatientsafetyreportingsystem)「臺灣病人平安通報系統(tǒng)」以匿名,自願,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)行趨勢分析並對醫(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，進(jìn)一步營造平安之就醫(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：鼓勵異常事件通報資料正確性目標(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面對改變能及時與有效的應(yīng)對Learningculture觀察、反應(yīng)與分析、創(chuàng)新、行動

Source:JamesReason,managingtheriskoforganizationalaccidents

Safety–ComprisedofManyPiecesReportEducateInformAnalyzeTrustSafety–PuttingitAllTogetherReportEducateInformAnalyzeTrus