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醫療疏失擴散模型

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维基百科，自由的百科全书

醫療疏失擴散模型（英語：healthcare error proliferation model，簡稱HEPM）是英國曼徹斯特大學教授詹姆斯·瑞森（James Reason）所發表的瑞士奶酪模型的改編版本，用來說明：1. 現代醫療系統固有的複雜性，以及2. 這些系統裡面人為錯誤的歸因。HEPM[1]解釋疏失發生的原因和會導致的不良後果的事件序列。這個模型強調組織上和外部的文化在識別、預防、緩解、和防禦措施所能發揮的作用。

簡介

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醫療系統之所以複雜，是因為它們在結構（例如護理單位、藥房、急診室、手術室），還有專業（例如護理人員、醫生、藥劑師、行政管理人員、治療師）之上種類繁多，而關聯的要素之間能夠相互適應，並能從經驗中學習，以及改變。“複雜適應系統”（CAS）這個名詞是由在跨學科的聖菲研究所（SFI）的約翰·霍蘭德和默里·蓋爾曼兩位學者所提出。隨後，露絲·安德森（Ruth A. Anderson）、魯賓·麥克丹尼爾（Rubin McDaniels）、和保羅·西里爾斯（英语：Paul Cilliers）等學者把CAS的理論和研究擴展，納入社會科學（例如教育和醫療衛生）之中運用，。

模型概述

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HEPM把瑞士奶酪模型[2]理論用到具有複雜性質的醫療系統和集成架構之上。瑞士奶酪模型把複雜，而能自我適應的系統與多孔的瑞士奶酪切片相提並論。[2][3]切好的奶酪片被稱為防禦層，用來表達這些切片在系統中的作用和功能，而這些作用和功能具有攔截和防止危險的能力。這些防禦層代表離散的位置或是組織級別，而這些位置或組織級別可能本身具有錯誤，並讓錯誤發展。保護層的功能包含四種：1）組織領導能力，2）風險監督，3）不安全做法的情況，以及4）不安全執行後的結果。

HEPM把醫院描述為具有多個防禦層，配備有維持關鍵防禦工事所需的基本要素[4]。透過檢查防禦層的屬性，潛在的故障點，可顯示疏失發生的原因[5]。專家們討論在CAS中對這些保護層的重要性作檢查[6][7]，也把臨床醫生的心理安全列入考慮。這個HEPM把詹姆斯·瑞森的開創性理論更加擴展。

這個模型把CAS當作一種關鍵特性。這種複雜的系統有獨特的自我組織能力，同時透過非線性關係發揮相互作用[8][9]，其中專業人員充當信息處理者[10][11]並與環境共同演進[12]。醫療衛生提供者在系統中扮演不同的角色，使用不同的方法來處理信息，以解決組織內和跨組織之間的整體性問題。[13]

定義

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CAS是在一個醫療衛生提供機構中，同時有多種臨床和行政代理人做非線性的交互行動，而其中的作業人員和患者是信息處理者，全部會與環境共同演進，達到安全可靠，以患者為中心的結果（英语：patient-centered outcomes）。[14]

參見

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參考文獻

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  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. 

參考

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文章

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  • 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.

書籍

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

其他文獻

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複雜理論

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  • 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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