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1、醫療安全文化醫療安全文化台中榮總台中榮總 彭素貞護理長彭素貞護理長WHY?WHY?In low-tech area.However,newer technology doesnt eliminate errorNor does even newer technology話說話說 C.R.M.C.R.M.北城、崇愛北城、崇愛(2002)(2002)醫療疏失後，林醫療疏失後，林(2003)(2003)以航空人因工程理論追蹤病以航空人因工程理論追蹤病患風險因素。患風險因素。風險構面依序風險構面依序急診核心醫護人員能力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與家屬及病患溝通醫護人員之間溝通
2、醫護人員之間溝通醫護人員與軟體系統互動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硬體設備互動醫護人員與環境互動醫護人員與環境互動重要因素依序重要因素依序急診醫師專科知識不足急診醫師專科知識不足醫師與病患及家屬溝通不良醫師與病患及家屬溝通不良急診主治醫師人力不足急診主治醫師人力不足醫護人員醫療疏失風險認知不足醫護人員醫療疏失風險認知不足排班型態不合理排班型態不合理醫療糾紛發生比例較高的地方醫療糾紛發生比例較高的地方急診室急診室手術室手術室加護病房加護病房 (吳，吳，2002)2002)What is CRM?Using all the available resources info
3、rmation,equipment,and people to achieve safe and efficient flight operations”John Lauber(1977)What is CRM Training?What is CRM Training?CRM training provides a set of countermeasures against human error;it is based on the premise that human error is ubiquitousubiquitous and and inevitableinevitable.
4、(透過訓透過訓練杜絕以往認為是不可避免、比比皆是的人為疏失練杜絕以往認為是不可避免、比比皆是的人為疏失)Dr.Helmreich(1996)AVIATION vs.MEDICINEAVIATION vs.MEDICINE當白袍映上藍天當白袍映上藍天 So different,yet so similarSo different,yet so similarDetroit News and Free Press.Sunday,February 6,2000.RAND Study:Quality of Health Care Often Not OptimalPatients care often
5、 deficient,study says.Proper treatment given half the time.On average,doctors provide appropriate health care only half thetime,a landmark study of adults in 12 U.S.metropolitan areas suggests.Medical Care Often Not Optimal Failure to Treat Patients Fully Spans Range of What Is Expected of Physician
6、s and NursesStudy:U.S.Doctors are not following the guidelines for ordinary illnesses.The American healthcare system,often touted as a cutting-edge leader in the world,suddenlyfinds itself mired in serious questions about the ability of itshospitals and doctors to deliverquality care to millions.Med
7、ical errors corrodequality of healthcare system就醫自保完全手冊就醫自保完全手冊第一章第一章：台灣的醫療疏失：台灣的醫療疏失第二章：如何找對醫師第二章：如何找對醫師 醫療有所謂的不確定性，開錯刀時有所聞，不管醫師替你安排任何手術，你都要學會問清楚問清楚，醫師則必須說明白說明白；不清不楚不清不楚、不明不白不明不白的手術，千萬別做。手術前三思八問三思而後行三思而後行，八問而後動八問而後動 YOU MAKE YOU MAKE ERRORS!ERRORS!To make people change To make people change Human E
8、rror TypeH1-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 FailureInappropriate handling of its systems力有未逮H4 Incapacitationphysical or psycho
9、logical 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)Unaware
10、ness-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.Inappropriate handling of aircraft or its systems-this can include misjudgment,maki
11、ng an incorrect decision-it can be exacerbated by lack of experience,lack of training or simple incompetence.H3 -Proficiency Failure力有未逮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 pursu
12、it safety,which requires nonstop efforts.(.(.(.(心態、承諾、契而不心態、承諾、契而不心態、承諾、契而不心態、承諾、契而不捨的追蹤捨的追蹤捨的追蹤捨的追蹤)To make people change,To make people change,what we need is what we need is Culture DefinitionsUsually based upon a blend of visionary ideas,corporate culture appears to reflect shared behaviors,beli
13、efs,attitudes and values regarding organisational goals,functions and procedures which are seen to characterise particular organisationsFurnham,A.,Gunter,B.,1993.Corporate Assessment.Routledge,London.Culture and SafetyAccording to the Institute of Medicine(IOM),the biggest challenge to moving toward
14、 a safer health system is changing the culture from one of blaming individuals for errors to one in which errors are treated not as personal failures,but opportunities to improve the system and prevent harmA Safety Culture isA Safety Culture isConstant awareness of potential for things to go Constan
15、t awareness of potential for things to go wrongwrong(持續監察潛在性問題進展為錯誤持續監察潛在性問題進展為錯誤)Culture that is open and fairCulture that is open and fair(文化是開放和公平的文化是開放和公平的)Culture that encourages people to speak up Culture that encourages people to speak up about mistakesabout mistakes(文化是讓人有有勇氣說出錯誤文化是讓人有有勇氣說出錯
16、誤)Able to learn about what is wrong and then put Able to learn about what is wrong and then put things rightthings right(是爲了學習作對的事是爲了學習作對的事)NPSANPSA病態期病態期只要不被抓到誰在乎資訊資訊反應期反應期安全很重要只要出問題一定處理管理期管理期具備危害管理的機制活化期活化期安全是我的責任主動處理問題新生期新生期安全是組織的一部分員工主動參與信任信任病人安全文化的演進病人安全文化的演進（石崇良，（石崇良，2005）1987年-2006年底，醫事審議委醫事審
17、議委員員20年來共完成5381份醫療訴訟鑑定報告，最後有11約590多案被鑑定為醫事人員有疏失，6為可能有疏失，而醫事人員大部份是醫師。其中外科佔34最多、內科近30、婦產科15。5000多宗醫療訴訟案中，有60 病人死亡，重傷害有25。資料來源：資料來源：20072007年年1111月月1919日蘋果日蘋果日報日報國內統計國內統計Swiss Cheese ModelSwiss Cheese Model If all the barriers are failed.If all the barriers are failed.providerspatientsProcedure policyA
18、ccidentAccidentPeripheralsproductsThe truth isThe truth is.醫療事件錯誤事件是一連醫療事件錯誤事件是一連 串疏失所造成串疏失所造成 多半的醫療不良事件並多半的醫療不良事件並 非個人疏忽或缺乏訓練非個人疏忽或缺乏訓練7575的醫療問題來自系的醫療問題來自系 統的錯誤統的錯誤providerspatientsProcedure policyPeripheralsproductsLatent failuresActive failures Stop the error!Stop the error!defences,barriers and
19、safeguardsPatient Safety:Leadership RoleOur systems are too complex to expect merely extraordinary people to perform perfectly 100 percent of the time.We as leaders have a responsibility to put in place systems to support safe practice.”*.90 X.90 X.90 X.90=.65 or 65%*Leadership Guide to Patient Safe
20、ty,Institute for Healthcare Improvement,2005 醫療異常事件醫療異常事件醫療錯誤醫療錯誤(Medical error)(Medical error)醫療不良事件醫療不良事件(Medical adverse event)(Medical adverse event)警訊事件警訊事件(Sentinel event)(Sentinel event)醫策會醫策會20052005醫療不良事件醫療不良事件 Medical Adverse Medical Adverse Events Events 傷害事件並非導因於原有的疾病本身傷害事件並非導因於原有的疾病本身，而
21、是由，而是由於醫療行為造成病人身體受到傷害、住院時間於醫療行為造成病人身體受到傷害、住院時間延長，或在離院時仍帶有某種程度的失能、甚延長，或在離院時仍帶有某種程度的失能、甚至死亡。至死亡。醫策會醫策會2005醫療體系醫療體系組織架構組織架構法律約束法律約束醫療環境醫療環境工作性質工作性質工作流程工作流程作業標準作業標準檢核制度檢核制度醫院管理醫院管理財務限制財務限制安全文化安全文化品質管控品質管控工作環境工作環境工作負擔工作負擔人力配置人力配置設備維護設備維護行政支援行政支援團隊因素團隊因素溝通不良溝通不良領導統馭領導統馭監督指導監督指導病人因素病人因素複雜嚴重度複雜嚴重度溝通能力溝通能力社會
22、條件社會條件個人喜好個人喜好個人因素個人因素知識不足知識不足技術不熟練技術不熟練身體心智狀態身體心智狀態醫療不良事件醫療不良事件Patient Safety is Patient Safety is No Accident No AccidentTPRTPR(Taiwan patient safety reporting(Taiwan patient safety reporting system)system)台灣病人安全通報系統以 匿名匿名,自願自願,保密保密,不究責不究責,共同學習共同學習 五大宗旨為出發點。收集多方的病人安全相關經驗，進行趨勢分析並對醫療機構提出警示訊息及學習案例。建立
23、機構間經驗分享以及資訊交流之平台，進一步營造安全之就醫環境。20102010醫療品質及病人安全工作目標醫療品質及病人安全工作目標目標一：提升用藥安全目標二：落實醫療機構感染控制目標三：提升手術安全目標四：預防病人跌倒及降低傷害程度目標五：鼓勵異常事件通報資料正確性目標六：提升醫療照顧人員間溝通的有效性目標七：鼓勵病人及其家屬參與病人安全工作目標八：提升管路安全目標九：消防安全Creating a Culture of Safety如何提昇安全文化如何提昇安全文化四要素四要素Reporting culture 建立信任的機制Justice culture 懲罰與歸責的拿捏Flexible cul
24、ture 面對改變能及時與有效的應對Learning culture 觀察、反應與分析、創新、行動 Source:James Reason,managing the risk of organizational accidents Safety Comprised of Many Safety Comprised of Many PiecesPiecesReportEducateEducateInformAnalyzeTrustSafety Putting it All TogetherReportEducateInformAnalyzeTrustMore than a program Saf
25、ety is a way of life改變安全文化的要點TEAM WORKLEADER SHIPWORKLOAD MANAGEMENTCOMMUNICATIONThe Role of the Patient Safety ManagerSeven steps to patient safety Step OneBuild a safety culture建立開誠佈公的病安文化建立開誠佈公的病安文化Create a culture where safety is considered in everything they doStep TwoLead and support staff領導者對
26、病安的堅持與支持領導者對病安的堅持與支持Lead and support your staffStep ThreeIntegrate your risk management activity整合風險管理整合風險管理Step FourPromote Reporting鼓勵通報鼓勵通報Spot and report mistakes when they happenStep FivePatient And Public Involvement鼓勵民眾共同參與病安工作鼓勵民眾共同參與病安工作Step SixLearn and share safety lessons學習並分享病安工作成效學習並分享病安工作成效Root Cause AnalysisStep SevenImplement solutions to prevent harm提供解決方案避免病安傷害提供解決方案避免病安傷害Make solutions simple and intuitive