Improving performance reliability in surgical systems

被引：19

作者：

Benn J. ^{[1
]}

Healey A.N. ^{[1
]}

Hollnagel E. ^{[2
]}

机构：

[1] Department of Biosurgery and Surgical Technology, Imperial College London, St. Mary's Hospital, Paddington, London W2 1NY, Praed Street

[2] Linköpings Universitet, Linköping

来源：

Cognition, Technology & Work | 2008年 / 10卷 / 4期

基金：

英国工程与自然科学研究理事会;

关键词：

Continuous quality improvement; Health care systems; High-reliability organisations; Reliability; Resilience engineering; Safety management; Surgery; Teams;

D O I：

10.1007/s10111-007-0092-x

中图分类号：

学科分类号：

摘要：

Health care has evolved rapidly to meet the medical demands of society, but not to meet the demands of consistent operational safety. In other high risk domains in which the consequences of systems failure are unacceptable, organisational and operational work systems have been developed to deliver consistent, high-quality, failure-free performance. In this paper we review contributions to a special issue of Cognition, Technology and Work on 'Enhancing Surgical Systems'. We consider their implications for improving the reliability of care processes in light of theoretical developments in the area of high-reliability organisations and resilience engineering. Health care must move from reactive safety cultures to be more proactively resilient to the continual threats posed by complexity in clinical care processes and the multi-professional hospital environment. Our analysis emphasises the importance of team working for reliable operational performance. A schematic framework to illustrate how safety interventions in surgery might cohere within an organisational strategy for achieving high-reliability is proposed. The implications for continuous quality improvement and effective regulation of system safety over differing time scales and organisational levels are discussed. © 2007 Springer-Verlag London Limited.

引用

页码：323 / 333

页数：10

共 48 条

[1]

Amalberti R., Vincent C., Auroy Y., De Saint Maurice G., Violations and migrations in health care: A framework for understanding and management, Qual Saf Health Care, 15, (2006)

[2]

Argyris C., Schon D.A., Organizational Learning: A Theory of Action Perspective, (1978)

[3]

Baker D.P., Gustafson S., Beaubien J., Salas E., Barach P., Medical Teamwork and Patient Safety: The Evidence-based Relation, (2005)

[4]

Baker D.P., Day R., Salas E., Teamwork as an essential component of high-reliability organizations, Health Serv Res, 41, pp. 1576-1598, (2006)

[5]

Borrill C.S., Carletta J., Carter A.J., Dawson J.F., Garrod S., Rees A., Et al., The Effectiveness of Health Care Teams in the National Health Service, (2002)

[6]

Brennan T.A., Leape L.L., Laird N.M., Hebert L., Localio A.R., Lawthers A.G., Et al., Incidence of adverse events and negligence in hospitalized patients: Results of the Harvard Medical Practice Study I., N Engl J Med, 324, pp. 370-376, (1991)

[7]

Burke C.S., Wilson K.A., Salas E., The use of a team-based strategy for organizational transformation: Guidance for moving toward a high reliability organization, Theor Issues Ergon Sci, 6, pp. 509-530, (2005)

[8]

Calland J.F., Guerlain S., Adams R.B., Tribble C.G., Foley E., Chekan E.G., A systems approach to surgical safety, Surg Endosc, 16, pp. 1005-1014, (2002)

[9]

Carthey J., De Leval M.R., Reason J.T., The human factor in cardiac surgery: Errors and near misses in a high technology medical domain, Ann Thorac Surg, 72, pp. 300-305, (2001)

[10]

Carthey J., De Leval M.R., Reason J.T., Institutional resilience in healthcare systems, Qual Saf Health Care, 10, pp. 29-32, (2001)

← 1 2 3 4 5 →