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險因素。風險構面依序急診核心醫(yī)護人員能力醫(yī)護人員與家屬及病患溝通醫(yī)護人員之間溝通醫(yī)護人員與軟體系統(tǒng)互動醫(yī)護人員與硬體設備互動醫(yī)護人員與環(huán)境互動重要因素依序急診醫(yī)師?？浦R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)護人員醫(yī)療疏失風險認知缺乏排班型態(tài)不合理醫(yī)療糾紛發(fā)生比例較高的地方急診室手術室加護病房

(吳，2002)

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

CRMtrainingprovidesasetofcountermeasuresagainsthumanerror;itisbasedonthepremisethathumanerrorisubiquitousandinevitable.(透過訓練杜絕以往認為是不可防止、比比皆是的人為疏失)Dr.Helmreich(1996)AVIATIONvs.MEDICINE當白袍映上藍天…

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，你都要學會「問清楚」，醫(yī)師則必須「說明白」；不清不楚、不明不白的手術，千萬別做。手術前「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(是爲了學習作對的事)

NPSA病態(tài)期只要不被抓到誰在乎資訊反應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制活化期平安是我的責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〔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34％最多、內科近30％、婦產科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)療體系組織架構法律約束醫(yī)療環(huán)境工作性質工作流程作業(yè)標準檢核制度醫(yī)院管理財務限制平安文化品質管控工作環(huán)境工作負擔人力配置設備維護行政支援團隊因素溝通不良領導統(tǒng)馭監(jiān)督指導病人因素複雜嚴重度溝通能力社會條件個人喜好個人因素知識缺乏技術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,共同學習五大宗旨為出發(fā)點。收集多方的病人平安相關經驗，進行趨勢分析並對醫(yī)療機構提出警示訊息及學習案例。建立機構間經驗分享以及資訊交流之平臺，進一步營造平安之就醫(yī)環(huán)境。2021醫(yī)療品質及病人平安工作目標目標一：提升用藥平安目標二：落實醫(yī)療機構感染控制目標三：提升手術平安目標四：預防病人跌倒及降低傷害程度目標五：鼓勵異常事件通報資料正確性目標六：提升醫(yī)療照顧人員間溝通的有效性目標七：鼓勵病人及其家屬參與病人平安工作目標八：提升管路平安目標九：消防平安CreatingaCultureofSafety如何提昇平安文化﹙四要素﹚Reportingculture建立信任的機制Justiceculture懲罰與歸責的拿捏Flexibleculture面對改變能及時與有效的應對Learningculture觀察、反應與分析、創(chuàng)新、行動

Source:JamesReason,managingtheriskoforganizationalaccidents

Safety–ComprisedofManyPiecesReportEducateInformAnalyzeTrustSafety–PuttingitAllTogetherReportEducateInformAnalyzeTrus