“瑞士奶酪模型”用于临床风险管控

“Swiss Cheese Model” for Clinical Risk Management and Control

"累积行为效应"也被称为"瑞士奶酪模型"。该"模型"用于航空安全管理已经多年,近年有学者尝试用于医疗安全管理,并取得了一定的成绩;本研究自2011年开始"患者安全目标管理",并在管理目标推进的过程中,将"累积行为效应"理论即"瑞士奶酪模型"和PDCA持续改进法则用于患者安全管理,完善了诸多医疗制度和诊疗流程。如不良事件报告制度、医技危急值管理制度、手术标识制度、手术安全核查制度、重大手术风险评估制度,危重病人交接流程、心肺复苏急救流程等。"瑞士奶酪模型"用于临床风险管控,减少了医疗损害的发生,产生了良好的社会效益和经济效益。

＂Accumulative Behavioral Effects＂ is also known as ＂Swiss Cheese Model＂. Such ＂model＂ has been applied in aviation safety management for many years, and been tried for medical safety management in recent years and achieved certain good results. ＂Patient Safety Management by Objectives＂ was put into practice in 2011, when ＂Accumulative Behavioral Effects＂, ＂Swiss Cheese Model＂ and PDCA （Plan Do Check Action） were used in the patient safety management to improve many medical system and medical service process, such as the adverse events reporting system, critical values of medical technology management system, the operation identification system, surgical safety verification system, major surgery risk assessment system, the transition process of critically ill patients, and cardiopulmonary resuscitation processes. ＂Swiss Cheese Model＂ is helpful to control clinical risks and decrease medical damage, resulting in good social and economic effects.