基于SHEL模型的救护车引发医疗损害责任的风险探讨

Risk exploration of liability for medical damages incurred by ambulances based on SHEL model

目的分析我国救护车管理过程中的医疗损害责任风险因素,为加强救护车管理,健全院前急救体系提供参考。方法以中国裁判文书网2013—2022年发布的,由救护车管理不当导致患者损害的裁判文书作为样本。基于SHEL模型中对软件、硬件、环境和人件4个要素的设定,采用文本分析法,运用NVivo 12.0软件按照"主范畴-次范畴-风险行为"对文本内容进行三级编码。结果共纳入有效样本文书136份,最终确定软件、硬件、环境、人件4个主范畴,院前急救管理者的职业意识及能力、医护人员的职业意识、医护人员的业务素质及能力、车载装备等11个次范畴,以及30种风险行为。对风险行为进行编码共获得187个参考点,参考点数相对较多的风险行为包括院前急救管理者未派车(45个),车内设备不完善、故障或无备用设备(20个),医护人员在车内未采取救治措施(18个),未派遣随车医护人员或担架员(14个),未配备足够药物(14个),以及驾驶员因急刹等导致患者或医疗仪器跌落(6个)等。结论救护车配备不足、急救系统人力资源短缺、急救车内设备及药物配备不够完善、驾驶员的行车安全存在问题等是我国救护车管理中的风险因素。建议扩充急救人才队伍,提升急救能力;合理配备救护车辆,完善急救网络建设;制定药品设备清单,建立预警机制;加强多方协调,提高送诊效率,以进一步降低风险概率,确保急救质量,提升院前急救效果。

Objective To analyze the risk factors of medical damage liability in the ambulance management in China,and provide reference for strengthening such management and improving the pre-hospital emergency system.Methods The judgment documents released by China Judgment Online from 2013 to 2022 regarding damages incurred by improper ambulance management,were used as the sample.Based on the setting of such elements as software,hardware,environment,and liveware in the SHEL model,the text analysis method was applied to encode the text content at three levels according to"main category-sub category-risk behavior"by means of NVivo 12.0 software.Results A total of 136 valid sample documents were included,finalizing such four main categories as software,hardware,environment,and liveware.Also finalized were 11 subcategories and 30 risk behaviors.The subcategories included the professional awareness and ability of pre-hospital emergency managers,the professional awareness of medical staff,the professional quality and ability of medical staff,as well as vehicle equipment among others.A total of 187 reference points were identified for coding risk behaviors.Risk behaviors with higher reference points included failure of pre-hospital emergency managers to dispatch vehicles(45),incomplete,malfunctioning,or no backup equipment in vehicles(20),failure of medical staff to take treatment measures in vehicles(18),failure to dispatch accompanying medical staff or stretchers(14),and insufficient medication(14),and fall of patients or medical equipment incurred by sudden braking of the drivers(6)among others.Conclusions Insufficient ambulance equipment,shortage of human resources in the emergency system,inadequate equipment and medication in emergency vehicles,and safety issues for drivers are risk factors in the management of ambulances in China.It is recommended to expand the first aid talent team and enhance first aid capabilities;Reasonably deploy ambulance vehicles and improve the emergency networks;Develop a list of pharmaceutical equipment and establish an early warning mechanism;Strengthen the multi-party coordination,improve the efficiency of referral,further reduce the probability of risk,ensure the quality of emergency treatment,and enhance the effectiveness of pre-hospital emergency treatment.