人因失误分类理论及其在医疗领域中的应用

Human Error Taxonomy Theory and Its Application in Medical Field

目的介绍人因失误的定义、分类方法及其在医疗领域中的应用。方法总结了4种人因失误分类方法,包括Norman分类法、Rasmussen分类法、Reason模型和Eindhoven分类法,并指出各个方法的特点和适用情况,列举其在输血系统、药物治疗、外科手术和麻醉等医疗失误分类分析中的应用。结果人因失误分类方法可用于医疗领域中的人因失误分析,其中系统性人误分类方法更适用于医疗环境。结论人误分类能够辅助分析医疗不良事件或事故的深层原因,为减少医疗失误或实施补救措施提供指导,改善患者安全。

Objective To introduce the definition and taxonomic methods of human error, and its applications in medical filed. Methods Four taxonomies of human errors are summarized, including Norman taxonomy, Rasmussen taxonomy, Reason model and Eindhoven taxonomy. The characteristics and the application scope of each taxonomic method are presented, and then the applications of these methods in some medical error classification analysis are discussed, such as transfusion system, medications, surgery and anesthesia. Results Human error taxonomic methods can be used to analyze human errors in medical field, among which the systematic, taxonomic method is more suitable for medical surroundings. Conclusion Human error taxonomies can assist analysing underlying factors in medical adverse events or accidents, provide guidance for reducing medical errors or carrying out remedial actions, improve patient safety.