Framework for analysing risk and safety in clinical medicine
Framework for analysing risk and safety in clinical medicine
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DOI：
10.1136/bmj.316.7138.1154
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发表时间：
1998-04-11
影响因子：
--
通讯作者：
Stanhope, N
中科院分区：
文献类型：
--
作者：
Vincent, C;Taylor-Adams, S;Stanhope, N
不良事件是指患者因治疗而无意中受到伤害的事件。麻醉期间的意识、手术中的死亡和漏诊的脑膜炎病例对患者和工作人员都是悲剧性的，可能会导致投诉或诉讼。调查通常集中于个别医生的行为，很少审查这些事件的背景。在最近的一个病例中，病人在手术时肠穿孔，检查医疗记录导致了对外科医生的批评。直到后来才发现，由于几个设备和电力问题，手术是在近乎黑暗的情况下进行的。不良事件通常起源于在不同层面上运行的各种系统性特征--任务、团队、工作环境和组织。我们提出了一个框架，旨在涵盖影响临床实践的许多因素。它可用于指导对事件的调查，产生评估风险的方法，并将研究重点放在不良后果的原因和预防上。
Adverse events are incidents in which a patient is unintentionally harmed by medical treatment. Awareness while under anaesthetic, deaths during surgery, and missed cases of meningitis are tragic for both patients and staff, and may lead to complaints or litigation. Investigations usually focus on the actions of individual doctors and seldom examine the background to these events.In a recent case of a patient whose bowel was perforated during surgery, examination of the medical records led to criticism of the surgeon. Only later did it emerge that the operation had been carried out in near darkness because of several equipment and power problems. Adverse events usually originate in a variety of systemic features operating at different levels—the task, the team, the work environment, and the organisation. We present a framework that aims to encompass the many factors influencing clinical practice. It can be used to guide the investigation of incidents, to generate ways of assessing risk, and to focus research on the causes and prevention of adverse outcomes.