醫療安全文化.pptVIP

醫療安全文化 台中榮總 彭素貞護理長 話說 C. R. M. 北城、崇愛(2002)醫療疏失後，林(2003)以航空人因工程理論追蹤病患風險因素。 風險構面依序 急診核心醫護人員能力 醫護人員與家屬及病患溝通 醫護人員之間溝通 醫護人員與軟體系統互動 醫護人員與硬體設備互動 醫護人員與環境互動 重要因素依序 急診醫師專科知識不足 醫師與病患及家屬溝通不良 急診主治醫師人力不足 醫護人員醫療疏失風險認知不足 排班型態不合理 醫療糾紛發生比例較高的地方 急診室 手術室 加護病房 (吳，2002) RAND Study: Quality of Health Care Often Not Optimal Human Error Type H1 - Active Failure-(Aware) Non adherence to standards and procedures 明知故犯 H2 - Passive Failure-(Unaware) breakdown of coordination, misunderstanding, communication failures, lack of expected support 無心之過 H3 - Proficiency Failure Inappropriate handling of its systems 力有未逮 H4 – Incapacitation physical or psychological inability 失能 H1 - Active Failure明知故犯 (Aware) Non adherence to standards and procedures - this can include non adherence to SOP, law violations, failure to follow written instructions, failure to manage cockpit resources, gross lack of appropriate vigilance, laziness. H2 - Passive Failure無心之過 (Unaware) Unawareness - this can include breakdown of coordination, misunderstanding, communication failures, lack of expected support, - it can be exacerbated by high workload, distraction, complacency, forgetfulness, boredom, low arousal level. H3 - Proficiency Failure力有未逮 Inappropriate handling of aircraft or its systems - this can include misjudgment, making an incorrect decision - it can be exacerbated by lack of experience, lack of training or simple incompetence. H4 – Incapacitation失能 Flight crew member unable to perform his/her duty due to physical or psychological inability. SAFETY CULTURE It is the mindset commitment to pursuit safety, which requires nonstop efforts.(心態、承諾、契而不捨的追蹤) Culture Definitions Usually based upon a blend of visionary ideas, corporate culture appears to reflect shared behaviors, beliefs, attitudes and values regarding organisational goals, functions and procedu