Patient-Safety课件.pptVIP

Patient Safety,High Reliability,and Risk Management Allan Frankel MD Director of Patient Safety Partners Healthcare System Boston, Massachusetts Summer, 2003 The Goal of Patient SafetyISHigh Reliability High Reliability Known to be highly risky but also highly safe and effective. The most important goal of Risk Management ISHigh Reliability High Reliability Known to be highly risky but also highly safe and effective. Highly reliable industries/organizations: Aviation industry Korean War Nuclear power plants 3 Mile Island Chemical industries Union Carbide in Bhopal ?Catholic Church Boston Sexual Abuse Hypotheses The conceptual frameworks for Patient Safety, High Reliability and Risk Management are one and the same. The current legal processes impacting the healthcare industry undermine high reliability and subvert risk management. Change for the better is possible, and will occur through cultural remodeling by leadership and risk management. Components of this talk The Nature of Systems (Healthcare) The Nature of Human Beings An Explanation of Individual Interest The Nature of Accountability The Nature of Risk Management Proof of Hypotheses Actions Professionally Personally The Nature of Systems(Healthcare industry) HealthCare is Complex Define complexity Complex systems Probability of Performing Perfectly: High Reliability Organizations Manage Complexity and the Unexpected with Five Characteristics: 1. Preoccupation with failure (safety) 2. Deference to expertise 3. Sensitivity to operations 4. Commitment to resilience 5. Reluctance to simplify interpretation Is HealthCare Highly Reliable? HRO characteristics 1. Preoccupation with Failure (Safety) 2. Deference to expertise 3. Sensitivity to operations 3. Commitment to resilience 5. Reluctant to simplify interpretation Fixing HealthCare:Application of Human Factors Human Factors – the study of the interface between humans, their environment, and technology Standardization Simplification Forcing Functions/