医疗活动中的人为错误及其防范

Human errors in medical practice and the prevention

人为错误是与主观愿望相违背的计划错误或执行错误。医疗活动中的人为错误是导致医疗事故的重要原因。常见的有手术部位错误、药物误用、治疗方案错误、医嘱误写误读、设备误接误操作等。防范医疗活动中的人为错误可以结合国内和国外的经验，从人员角度和系统角度着手，加强员工教育，改进操作流程，改善硬件设施。对有风险的技术操作设置多重安全措施，以增加打断事故发生链的概率，如手术部位预先画标记和多部门合作核对，用药前人工核对与计算机条形码匹配相结合，采用规范的临床路径等。管理层和一线员工都要对医疗差错有理性认识，鼓励基层上报差错事故，借以发现问题并进行持续质量改进。

Human errors are errors found in planning or implementation, and those found in medical practice are often major causes of mishaps. To name a few, wrong-site surgery, medication error, wrong treatment, and inadvertent equipment operation. Errors of this category can be prevented by learning from experiences and achievement worldwide. Preventive measures include those taken in human aspect and system aspect, reinforced education and training, process optimization, and hardware redesign. These measures can be aided by multiple safety steps in risky technical operations, in an effort to break the accident chain. For example, pre-operative surgical site marking, multi-department cooperated patient identification, bar-coded medication delivery, read-back during verbal communication, and observation of clinical pathway. Continuous quality improvement may be achieved when both the management and staff see medical errors in the correct sense, and frontline staff are willing to report their errors.