医疗安全文化

醫療安全文化台中榮總彭素貞護理長WHY?Inlow-techarea...However,newertechnologydoesn’teliminateerrorNordoesevennewertechnology話說

C.R.M.北城、崇愛(2023)醫療疏失後，林(2023)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護人員力量醫護人員與家屬及病患溝通醫護人員之間溝通醫護人員與軟體系統互動醫護人員與硬體設備互動醫護人員與環境互動重要因素依序急診醫師專科知識缺乏醫師與病患及家屬溝通不良急診主治醫師人力缺乏醫護人員醫療疏失風險認知缺乏排班型態不合理醫療糾紛發生比例較高的地方急診室手術室加護病房(吳，2023)

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

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

Sodifferent,yetsosimilarDetroitNewsandFreePress.Sunday,February6,2023.RANDStudy:QualityofHealth

CareOftenNotOptimalPatients’careoftendeficient,studysays.Propertreatmentgivenhalfthetime.Onaverage,doctorsprovideappropriatehealthcareonlyhalfthetime,alandmarkstudyofadultsin12U.S.metropolitanareassuggests.MedicalCareOftenNotOptimalFailuretoTreatPatientsFullySpansRangeofWhatIsExpectedofPhysiciansandNursesStudy:U.S.Doctorsarenotfollowingtheguidelinesforordinaryillnesses.TheAmericanhealthcaresystem,oftentoutedasacutting-edgeleaderintheworld,suddenlyfindsitselfmiredinseriousquestionsabouttheabilityofitshospitalsanddoctorstodeliverqualitycaretomillions.Medicalerrorscorrodequalityofhealthcaresystem就醫自保完全手冊第一章：台灣的醫療疏失其次章：如何找對醫師…醫療有所謂的不確定性，開錯刀時有所聞，不管醫師替你安排任何手術，你都要學會「問清晰」，醫師則必須「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、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(持續監察潛在性問題進展為錯誤)Culturethatisopenandfair(文化是開放和公正的)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病態期只要不被抓到誰在乎資訊反應期安全很重要只要出問題肯定處理治理期具備危害治理的機制活化期安全是我的責任主動處理問題新生期安全是組織的一局部員工主動參與信任病人安全文化的演進〔石崇良，2023〕1987年-2023年底，醫事審議委員20年來共完成5381份醫療訴訟鑑定報告，最後有11％﹙約590多案﹚被鑑定為醫事人員有疏失，6％為可能有疏失，而醫事人員大部份是醫師。其中外科佔34％最多、內科近30％、婦產科15％。5000多宗醫療訴訟案中，有60％病人死亡，重傷害有25％。資料來源：2023年11月19日蘋果日報國內統計SwissCheeseModel

Ifallthebarriersarefailed..

providerspatientsProcedurepolicyAccidentPeripheralsproductsThetruthis…..↗醫療大事錯誤大事是一連串疏失所造成↗多半的醫療不良大事並非個人疏忽或缺乏訓練↗75％的醫療問題來自系統的錯誤providerspatientsProcedurepolicyPeripheralsproductsLatentfailuresActivefailures

Stoptheerror!defences,barriersandsafeguardsPatientSafety:LeadershipRoleOursystemsaretoocomplextoexpectmerelyextraordinarypeopletoperformperfectly100percentofthetime.Weasleadershavearesponsibilitytoputinplacesystemstosupportsafepractice.”*.90X.90X.90X.90=.65or65%**LeadershipGuidetoPatientSafety,InstituteforHealthcareImprovement,2023醫療異常大事醫療錯誤(Medicalerror)醫療不良大事(Medicaladverseevent)警訊大事(Sentinelevent)醫策會2023醫療不良大事﹙MedicalAdverseEvents﹚傷害大事並非導因於原有的疾病本身，而是由於醫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。醫策會2023醫療體系組織架構法律約束醫療環境工作性質工作流程作業標準檢核制度醫院治理財務限制安全文化品質管控工作環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馭監督指導病人因素複雜嚴重度溝通力量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醫療不良大事

PatientSafetyis

NoAccident

TPR

(Taiwanpatientsafetyreportingsystem)「台灣病人安全通報系統」以匿名,自願,保密,不究責,共同學習五大宗旨為出發點。收集多方的病人安全相關經驗，進行趨勢分析並對醫療機構提出警示訊息及學習案例。建立機構間經驗共享以及資訊沟通之平台，進一步營造安全之就醫環境。2023醫療品質及病人安全工作目標目標一：提升用藥安全目標二：落實醫療機構感染掌握目標三：提升手術安全目標四：預防病人跌倒及降低傷害程度目標五：鼓勵異常大事通報資料正確性目標六：提升醫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安全工作目標八：提升管路安全目標九：消防安全CreatingaCultureofSafety如何提昇安全文化﹙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、創新、行動

Source:JamesReason,managingtheriskoforganizationalaccidents

Safety–ComprisedofManyPiecesReportEducateInformAnalyzeTrustSafety–PuttingitAllTogetherReportEducateInformAn