人为错误对医疗程序的影响。

Pub Date : 2022-01-01 DOI:10.3233/JRS-210019
Daniela Frazão, José Sobral
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引用次数: 1

摘要

背景:几十年来,人们一直在研究人为错误,并将其特别应用于关键基础设施和过程,在这些基础设施和过程中,此类错误的影响可能导致严重或灾难性的后果。从这个意义上说,将这种分析扩展到医学等其他领域是至关重要的。目的:本研究提出了一种半定量的人为错误风险评估方法,包括对所谓的绩效形成因素(psf)的分析,以促进卫生服务的改善。方法:采用问卷调查的方法,包括考虑的PSF进行回答,以确定每个PSF的影响及其对人为错误的影响。它允许对患者(HERAp)和服务质量(HERAq)执行人为错误风险评估(HERA)。结果:影响因子最高的是PSFs。在采取纠正措施后,可以观察到对降低患者风险和提高服务质量的影响。结论:该方法的应用包括psf的影响,可以最大限度地减少或减轻风险较大的失效模式,并增加患者安全,促进更好的医疗程序质量。
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The impact of human error on medical procedures.

Background: Human error has been studied for large decades with special application to critical infrastructures and processes where the impact of such errors can induce severe or catastrophic consequences. In this sense it is of utmost importance to extend this type of analysis to other fields as medicine.

Objective: This study proposes a semi-quantitative human error risk assessment methodology, including the analysis of the so-called Performance Shaping Factors (PSFs), in order to contribute to health services improvement.

Methods: A questionnaire including the considered PSFs is answered in order to determine the impact of each PSF and its influence on human error. It allows performing a Human Error Risk Assessment (HERA) for both the patient (HERAp) and the quality of the service (HERAq).

Results: The results show the PSFs with the highest impact factor. After applying corrective measures, it is possible to observe the impact on the reduction of the risk for patient and for the quality of the service.

Conclusions: The application of the methodology with the inclusion of the impact of PSFs allows minimizing or mitigating failure modes with greater risk as well as increasing patient safety and promoting a better quality of medical procedures.

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