Health Care Error 醫療錯誤

The simplest definition of an error in health care is an unavoidable side effect of treatment, whether or not it is obviously harmful to the patient. On average, the two curators of the Institute for Medicine and Health Grades reports indicate that between 400,000-1.2 million deaths due to errors during 1996-2006 in the United States caused. These losses were partly due to:

The complexity of health care

• The technology is complex, powerful drugs.
• Intensive care, longer stay in hospital.

Systems and Process Design

• Poor communication, unclear lines of doctors, nurses and caregivers.
• Disconnected reporting systems in hospitals: the fragmented system that is in the numerous hand-offs of patients resulting lack of coordination and errors.
• The perception that the measures are considered by other groups within the institution.
• Prevent the use of automated systems to failure.
• Inadequate systems for sharing information about errors that contribute to the analysis of the causes and hamper strategies for improvement.
• Cost-cutting measures implemented by hospitals in response to the reduction of the refund.
• Environmental and design factors. In urgent cases, the patient care is delivered in the area as unsuitable for the monitoring of safety. The American Institute of Architects to identify safety issues related to the design and construction of facilities for health care.
• Failure of the infrastructure. According to WHO, 50% of medical equipment in developing countries are only partially usable because of the shortage of skilled labor or parts. Therefore, diagnostic procedures or treatments can be carried out, resulting in a lower quality of care.

The Joint Commission's Annual Report on Quality and Safety in 2007 found that inadequate communication between healthcare providers and between providers and patients and family members, responsible for more than half of serious adverse events in accredited hospitals. Other major causes include poor assessment of the patient, and a lack of guidance or training.

Skills, education and training

• Changes in the training of health providers and experience
• Will identify the frequency and severity of medical errors

Human Factors and Ergonomics

• Fatigue
• Depression and Burnout
• Several patients, unfamiliar situations, time constraints
• Complications increase as the increased ratio of staff-patient nurse
• Drug names that look similar and sound the same

最簡單的定義健康服務的錯誤是可以預防的不利影響照顧，是否明顯或有害的病人。保守的平均同時醫藥研究所HealthGrades所的報告表明，有萬之間400,000-1.2錯誤引起的死亡人數在1996-2006年間在美國。這些傷亡者中有，部分原因是：

保健複雜性

• 複雜的技術，有效的藥物。
• 重症監護，長期住院。

系統和工藝設計

• 缺乏溝通，界限不明，權力的醫生，護士和其他醫護服務。
• 斷開報告系統在醫院：支離破碎的系統，其中許多手權衡的結果的患者在缺乏協調和錯誤。
• 的印象，正採取行動的其他群體的機構。
• 依賴自動化系統，以防止錯誤。
• 不足系統共享信息的錯誤阻礙的成因分析和改進戰略。
• 削減成本措施，醫院應對償還削減。
• 環境及設計因素。在緊急情況下，病人護理可能呈現不適合的地區安全監測。美國建築師學會已確定關注的安全設計及建造保健設施。
• 基礎設施故障。根據世界衛生組織，50％的醫療設備在發展中國家使用的只是部分由於缺乏熟練的操作或部件。因此，診斷或治療程序無法執行，導致不規範治療。

聯合委員會的年度報告2007年質量與安全，發現不足，醫療服務提供者之間的溝通，或提供者和病人及其家庭成員，是根本原因，一半以上的嚴重不良反應事件在認證的醫院。其他領先的原因包括沒有充分評估病人的條件，領導不力或培訓。

能力，教育和培訓

• 變化的衛生保健提供者的培訓和經驗
• 不承認患病率和嚴重性的醫療差錯

人因工程

• 疲勞
• 抑鬱症和倦怠
• 多樣化的病人，陌生的環境，時間壓力
• 並發症病人增加護士人手比例增加
• 藥物名稱，外形相似或聲音都