Better names for ‘Never Events’
Better names for ‘Never Events’
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“从未发生过的事件”的更好名字
DOI：
10.1111/anae.13443
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发表时间：
2016
期刊：
影响因子：
10.7
通讯作者：
A. Smith
中科院分区：
文献类型：
--
作者：
M. A. Smith;A. Smith
Moppett和Moppett证明，从未发生的事件是随机的、罕见的事件，其发生率不一定与手术室表现不佳相对应;同样，没有从未发生的事件不一定等同于组织内明确的良好做法[1]。由于Never事件非常罕见，因此它们作为性能度量并不有用。在他的社论中，潘伟迪暗示它们总是会发生（尽管是随机的），尽管他没有把它们称为“总是但随机的事件”。我们想为Never Events建议其他替代名称，我们相信这将增强对安全的理解。正如安全专家Erik Hollnagel指出的那样，通过测量出了什么问题来判断安全性不可避免地会导致一个悖论：手术护理变得越安全，需要测量的就越少[3]。“永不发生事件”活动意味着在实践中消除变异，但由于这种变异是安全性信息的来源，因此随着安全性的增加，信息会减少。虽然手术和麻醉护理应尽可能安全，但从纯粹的统计学角度来看，如果Never事件发生更频繁，则可以更好地监测围手术期安全性。在这方面，他们可能更恰当地被称为“不经常足够的事件”。Harrop-Griffith的社论引用了两个安全“神话”：“完美神话”和“惩罚神话”。Besnard和Hollnagel讨论了其他六个安全神话，其中一个是“安全第一”的神话。虽然安全经常被公开吹嘘为组织的首要任务，但实际上它总是与效率等其他因素相权衡。如果我们认为“永不事件”的发生是完全不可接受的，那么“安全第一”的原则要求我们必须尽一切努力，付出一切可能和必要的代价，以消除它们。如果我们不准备这样做，以消除从来没有事件，那么我们应该改名为“尽可能少，我们可以负担得起的事件”。最后，比调查已经发生的错误更好的方法是了解日常工作实践中防止此类错误更频繁发生的原因。这种特性被称为“错误弹性”。Never事件使预防该事件成为主要考虑因素，但不一定能帮助我们理解在当前系统中，是什么允许事情在某些时候出错，而大多数时候，它们是正确的？将某些事件归类为“从未发生过的事件”，会使人们更加关注可能出现的问题，而不是将员工的注意力集中在如何加强他们的工作方式上，从而降低出错的可能性。使用“为什么它们不更频繁地发生事件”这个名称，肯定会引起人们对系统中“潜在成功”的思考。我们邀请其他读者设计其他名称，以帮助理解或提高围手术期安全性。
Moppett and Moppett demonstrate that Never Events are random, rare events whose incidence does not necessarily correspond with poor operating theatre performance; equally, the absence of Never Events does not necessarily equate to unequivocal good practice within an organisation [1]. As Never Events are so rare, they are not useful as a measure of performance. In his accompanying editorial, Pandit suggests they will always happen (though randomly), though he stops short of referring to them as ‘Always But Random Events’ [2]. We would like to suggest other alternative names for Never Events, which we believe will enhance the understanding of safety. As safety expert Erik Hollnagel notes, judging safety by measuring what goes wrong leads inevitably to a paradox: the safer surgical care becomes, the less there is to measure [3]. The Never Event campaign implies the elimination of variation in practice, but as this variation is the source of information about safety, the information reduces as safety increases. Whilst surgical and anaesthetic care should be as safe as possible, from a purely statistical point of view, if Never Events happened more often, they would provide a better monitor of perioperative safety. In this respect, they might more aptly be termed ‘Not Often Enough Events’. Harrop-Griffith’s editorial cited two safety ‘myths’: the ‘perfection myth’ and the ‘punishment myth’ [4]. Besnard and Hollnagel discuss six other safety myths, of which one is the ‘safety first’ myth [5]. Whilst safety is often publicly vaunted as an organisation’s top priority, in reality it is always traded off against other factors such as efficiency. If we believe that the occurrence of Never Events is completely unacceptable, the principle of ‘safety first’ dictates that we must go to every length, and meet every cost, possible and necessary in order to eliminate them. If we are not prepared to do this to eradicate Never Events, then we should rename them ‘As Infrequent As We Can Afford Events’. Finally, a better approach than investigating errors that have already occurred is to understand what it is about everyday work practices that prevents such errors from happening more often. This property is referred to as ‘resilience to error’. Never Events make prevention of that event the main consideration, but do not necessarily help us understand what is it in the current system that allows things to go wrong some of the time, when most of the time, they go right? Classifying certain occurrences as Never Events sharpens the focus on what might go wrong, rather than concentrating the minds of staff on how they might strengthen how they work so errors become less likely. It would surely direct attention to thinking about ‘latent successes’ in the system to use the name ‘Why Don’t They Happen More Often Events’. We invite other readers to devise other names to help understand or improve peri-operative safety.