Understanding Adverse Events: A Human Factors Framework

摘要: The complex and demanding clinical environment of nurses can be made a bit more understandable easier in which to deliver care by accounting for wide range human factors concerns that directly indirectly impact performance. Human is the application scientific knowledge about strengths limitations design systems work ensure safe satisfying A framework such as portrayed Figure 1 helps us become aware salient components their relationships shape influence quality provided patients. concept error somewhat loaded term. Rather than falling into trap uncritically focusing on searching individuals blame, approach attempts identify contributing substandard performance find ways better detect, recover from, or preclude problems could result harm Starting with individual characteristics providers knowledge, skills, sensory/physical capabilities, we examined hierarchy system factors, including nature performed, physical environment, human-system interfaces, organizational/social management, external factors. In our current fragmented health system, where no single entity charge, these multiple seem continuously misaligned interact manner leads care. These are proverbial accidents waiting happen. Nurses serve critical role at point patient care; they an excellent position not only problems, but help problems-behind-the-problems. actively practice tenets high-reliability organizations. It recognized, course, nursing cannot address all its own. Everyone who has potential care, matter how remote (e.g., device manufacturers, administrators, nurse managers), needs mindful interdependent play shaping. Without clear strong voice organizational climate conducive candidly addressing efforts improve safety will fall short potential.