Beyond Babel: prospects for a universal patient safety taxonomy.
Beyond Babel: prospects for a universal patient safety taxonomy.
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超越 Babel：通用患者安全分类法的前景。
DOI：
10.1093/intqhc/mzi029
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发表时间：
2005
期刊：
影响因子：
--
通讯作者：
Weingart,SaulN
中科院分区：
文献类型：
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作者：
Weingart,SaulN
耶和华说，看哪，他们是一样的人民，说一样的语言，这只是他们所要行的事的起头。来吧，我们下去，在那里变乱他们的言语，使他们的言语彼此不通。创世记11：6- 7那些熟悉病人安全领域的人会认识到，令人困惑的语言实际上并不需要神的干预。在短短几年的时间里，医疗差错和医源性损伤的语言已经演变成一种令人困惑的语言，困扰着人们对这种现象进行分类和理解的努力。安全的术语在一个好日子里是令人困惑的，在一个坏日子里几乎是不可能的。考虑一些常用的患者安全术语的例子。“不良反应”通常意味着药物或治疗的预期副作用。它类似于护理的“并发症”。相反，“不良事件”表示存在与医疗护理相关的损伤（预期或非预期）。但是，不同的用户需要不同的伤害水平，才能将事件定性为不良事件。“可预防的不良事件”从定义上讲是一种错误，但通常很难确定可预防性。“未遂事件”，也称为“侥幸脱险”，与“潜在不良事件”同义，通常被认为是可以预防的。“哨兵事件”是指导致或可能造成严重伤害的事件。“严重可报告事件”通常不向公共当局报告，尽管其名称如此。人们可以看到这些术语和概念是如何阻碍人们进行简单的交谈和思考的。也许巴比伦人过得很轻松。为了为改善患者安全性创造一个更加一致的基础，医学研究所的患者安全数据标准委员会主张制定一种更加周到和一致的方法来管理患者安全信息[1]。一个标准的词汇和分类方案将提供研究结果的比较，更好的基准跨卫生保健组织，可靠的区域和国家事件报告的发展，并允许计算机系统的互操作性，收集有关这些事件的信息进行分析，公共报告和政策制定。医疗机构认证联合委员会（JCAHO）的一组高级领导人已经概述了一个新的和全面的计划，用于定义和分类医疗错误-错误分类法。在本期杂志中，分类法值得认真考虑[2]。
And the Lord said,‘Behold, they are one people, and they have all one language; and this is only the beginning of what they will do... Come, let us go down, and there confuse their language, that they may not understand one another’s speech’. Genesis 11: 6–7Those familiar with the field of patient safety will recognize that confusing language does not, in fact, require divine intervention. In the space of a few years, a bewildering language of medical error and iatrogenic injury has evolved, bedeviling efforts to catalogue and understand this phenomenon. The terminology of safety is perplexing on a good day, and near impossible on a bad one. Consider a few examples of patient safety terms in common use. An ‘adverse reaction’usually connotes an anticipated side effect of a medication or treatment. It is similar to a ‘complication’of care. An ‘adverse event’, in contrast, signifies the presence of a medical carerelated injury (anticipated or not). However, different users require different levels of harm in order to qualify an incident as an adverse event. A ‘preventable adverse event’is an error by definition, but it is often difficult to ascertain preventability. A ‘near miss’, also called a ‘close call’, is synonymous with ‘potential adverse event’and is always considered to be preventable. A ‘sentinel event’refers to an incident that resulted in or might have produced a serious injury. A ‘serious reportable event’is often not reported to public authorities, its name notwithstanding. One can see how this thicket of terms and concepts gets in the way of plain talk and thought. Perhaps the Babel-ites had it easy. To create a more coherent basis for patient safety improvement, the Institute of Medicine’s Committee on Data Standards for Patient Safety advocated the development of a more thoughtful and consistent approach to the management of patient safety information [1]. A standard vocabulary and classification scheme would provide for comparison of research findings, better benchmarking across health care organizations, the development of reliable regional and national event reporting, and allow for interoperability of computer systems that collect information about these incidents for analysis, public reporting, and policy making. Jumping into the breach, a group of senior leaders from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has outlined a new and comprehensive scheme for defining and classifying medical errors—an error taxonomy. Featured in this issue of the Journal, the taxonomy bears serious consideration [2].