从个人观和系统观浅谈护理差错的管理

在管理学中，英国心理学家Reason对发生问题原因的认识提出了两种不同的观点，即个人观和系统观。“个人观”认为错误主要是个人原因引起的，是由于人们心理失常，如遗忘，注意力不集中，缺乏积极性，粗心大意等。而“系统观”认为，是人就会犯错误，即使最好机构内的优秀的工作人员都有可能犯错误，错误的原因主要是在于系统的问题而非人的行为失常。     

从个人观和系统观浅谈护理差错的管理

管理学中,英国心理学家Reason对发生问题原因的认识提出了两种不同的观点,即个人观和系统观."个人观"认为错误主要是个人原因引起的,是由于人们心理失常,如遗忘,注意力不集中,缺乏积极性,粗心大意等.而"系统观"认为.是人就会犯错误,即使最好机构内的优秀的工作人员都有可能犯错误,错误的原因主要是在于系统的问题而非人的行为失常.这些因素包括工作环境中错误反复发生的隐患以及引起这些错误的组织程序[1]".本研究通过我科7年内在护理工作中发生的差错,应用个人观和系统观进行分析,以探讨减少差错发生的有效对策,现报道如下.     

系统观在护理差错管理中的应用

英国心理学家R eason提出了两种对待错误的不同观念,即个人观和系统观。个人观认为错误主要是个人原因引起的,是由于人们的心理失常,如遗忘、注意力不集中、缺乏积极性、粗心大意、疏忽、轻率等。因此,防范错误的对策就是处罚犯错误的人。而系统观认为,是人就会犯错误,错误的原因主要在于系统问题而非人的行为失常,这些因素包括工作环境中错误反复发生的隐患,以及引起这些错误的组织程序。当错误发生后,事情的关键不是追究谁发生了错误,而是弄清系统出了什么问题,以及为什么出现这些问题。防范错误的对策是,从组织机构的角度系统设计防御错误的机制,减少人犯错误的环境和机会。现对系统观在护理差错管理中的应用探讨如下。     

精神分裂症患者拒药心理临床分析与护理对策

在精神病分裂症患者护理中由于病人自知力的丧失，治疗依从性极差，处理拒药行为是精神分裂症患者护理的工作重点之一。分析病人的拒药心理的产生与药物因素、疾病因素、心理因素、错误认知及错误的用药指导等因素有关，从而产生拒药行为、拒药言论、甚而产生敌对情绪和敌对行为，在护理中应重视药物知识宣教，疾病知识教育，加强心理护理及服药时的观察，使病人树立正确的疾病观，提高服药主动性。     

护士继续教育增设《健康教育学》课程的构想

由于新医学模式和新健康观的深入人心，世界范围内卫生工作的重点发生了转移。随之护理的理论、模式、权限、内容等都发生了变化，尤其以护理范围和护理对象的扩展最有代表意义，这些重要的划时代的变化，足以说明其动力所在，即社会发展和学科发展的双重需要。为了满足这两种需要，护士责无旁贷地成为健康教育工作的重要成员。然而目前广大护理人员，并未完全地及深刻地认识这一点。鉴于这种形势，有必要在护士继续教育中增设健康教育学课程。1认清形势．提高认识我校培养的护理人才分为大、中专两个层次，大专生主要通过三年函授教育来进…     

浅谈如何以整体护理观预防急诊医疗纠纷

目的：探讨如何以整体护理观预防急诊护理的医疗纠纷。方法：从急诊护理角度人手，以整体护理观为出发点．分别把患者视为生理的、心理的、社会的和文化的人来加以分析和揣摩，并给予适合不同个体需要的护理，从而对护理工作提出具体要求。结果：整体护理观在临床急诊护理中可提高医护质量，减少或避免护患矛盾发生．预防急诊护理纠纷的发生，起到预防医疗纠纷的作用。结论：整体护理观在预防急诊科的医疗纠纷中非常重要。     

“足”部医源性并发症的防治

骨折是常见的意外损伤之一，病人住院时间和卧床时间都相对较长，并且大部分需要施用骨牵引或石膏、小夹板制动。如果医护人员的专业意识及专业技术不强，疏忽了石膏固定和手术后的观察和护理，将导致“足”部医源性并发症的发生。有的医护人员对“足”部医源性并发症给患者带来的严重后果认识不足，错误的认为此并发症的发生是难免的，也构不上医疗事故。由于在这种错误的认识指导下．工作上稍有疏忽，往往给患者带来肉体上和精神上的痛苦和伤害，由此延长了住院时间，加重了经济负担，有的甚至造成终身残废。本组病例就是一个很深刻的经验教训。     

儿科健康教育中存在的问题及对策

随着人们对健康和疾病认识的不断提高，医学模式由原来的以疾病为中心的功能制护理转向以健康为中心的整体护理模式，实施健康教育是整体护理的重要组成部分，通过健康教育能帮助人们形成正确的行为和观念，促进病人身心健康。儿科俗称“哑科”，由于其特殊性，其护理工作面对的是患儿和家长两方面，而且患儿家长的心理工作占有相当大比例，所以在实施健康教育过程中往往存在着诸多不足之处，现提出来与护理同道共同探讨。     

急诊科护理记录中存在的问题及对策

护理记录是护理人员对病情观察和实施护理措施的原始文字记载，是病历的重要组成部分。随着《医疗事故处理条例》和“举证责任倒置”的实施，护理记录已成为具有法律效力的一种文书，也是判断医疗行为正确、及时、有效、安全的主要依据。由于急诊科护士工作繁忙，特别是患者危急。需要护士做出紧急处理，故常根据回忆补充记录，发生遗漏项目或记载错误，这种护理记录缺乏原始性和真实性，成为缺陷记录，失去了举证的价值。因此，护理人员必须增强法律意识，规范护理行为，防止医疗事故发生。     

整体护理中主管护士的体会

由于社会不断进步，科学日新月异，人民保健事业对护理工作的需求越来越高，使护理学发展迅速，护理工作从原来的功能制护理向责任制护理，整体护理转变。实施以病人为中心的整体护理，是一种护理活动形式。它以主管护士为主，以现代护理观为指导，以护理程序为框架，对病人的身心健康实施有计划、有针对性的、系统的、整体全面的护理。     

Changing culture in the home health setting: strategies for success

Organizational culture is generally defined as the internal attributes of the staff, such as their values, beliefs, and attitudes. Although technically accurate as a definition, personal attributes defy direct intervention, leading some to question whether it is possible to change culture. It is proposed that it is possible to change the personal internal attributes that define organizational culture by changing the characteristic structures and behaviors of the organization that shape those attributes. This model, called the Quality Capability Model, creates an approach to culture change that accommodates the unique features of home health.     

The current approach to human error and blame in the NHS

There is a large body of research to suggest that serious errors are widespread throughout medicine. The traditional response to these adverse events has been to adopt a 'person approach' - blaming the individual seen as 'responsible'. The culture of medicine is highly complicit in this response. Such an approach results in enormous personal costs to the individuals concerned and does little to address the root causes of errors and thus prevent their recurrence. Other industries, such as aviation, where safety is a paramount concern and which have similar structures to the medical profession, have, over the past decade or so, adopted a 'systems' approach to error, recognizing that human error is ubiquitous and inevitable and that systems need to be developed with this in mind. This approach has been highly successful, but has necessitated, first and foremost, a cultural shift. It is in the best interests of patients, and medical professionals alike, that such a shift is embraced in the NHS.     

Transdisciplinary approach: an atypical strategy for improving outcomes in rehabilitative and long-term acute care settings.

In the rehabilitation and long-term acute care settings, an atypical strategy has emerged in the past few years whereby the central focus is on improving patient care through a team approach in which responsibilities are shared and the normal boundaries of the healthcare professions blurred. This article provides a conceptual analysis of this unique, transdisciplinary approach to care delivery. Differentiation between interdisciplinary, multidisciplinary, and transdisciplinary techniques is provided through case scenarios. Defining attributes, necessary antecedents, and the many possible positive outcomes from the transdisciplinary approach to practice is discussed. This concept analysis defines for the rehabilitation or long-term acute care nurse a method that can be used to redesign care delivery, to promote improved patient outcomes, and to achieve a cohesive team environment.     

Storytelling effectively translates TeamSTEPPS skills into practice

This column shares the lived experiences of four Master Trainers who used storytelling as the methodology for teaching TeamSTEPPS to interprofessional staff members of a large health system. TeamSTEPPS is an evidence-based program that focuses on skills and behaviors that improve teamwork and communication, which are key to preventing medical errors.     

Comprehensive critical incident monitoring in a neonatal-pediatric intensive care unit: experience with the system approach

Objective: To examine the occurrence of critical incidents (CIs) in order to improve quality of care.¶Design: Prospective survey.¶Setting: Multidisciplinary, neonatal-pediatric intensive care unit (ICU) of a non-university, teaching children's hospital.¶Patients: Four hundred and sixty-seven admissions over a 1-year period.¶Methods: A CI is any event which could have reduced, or did reduce, the safety margin for the patient. Comprehensive, anonymous, non-punitive CI monitoring was undertaken. CI severity with respect to actual patient harm was graded: major (score 3), moderate (2) or minor (1). The system approach incorporates the philosophy that errors are evidence of deficiencies in systems, not in people. We undertook 2-monthly analyses of CIs.¶Results: There were 211 CI reports: 30 % major, 25 % moderate, 45 % minor. The CI categories were management/environment 29 %, drugs 29 %, procedures 18 %, respiration 14 %, equipment dysfunction 7 %, nosocomial infections 3 %. The respiratory CIs were the most severe, the drug-related CIs the least severe (score mean, SD: 2.9, 0.26 vs 1.4, 0.76; p < 0.001). However, 20 out of 62 drug-related CIs were potentially life-threatening. Thirteen percent of drug CIs were decimal point errors. Eleven of the 29 respiratory CIs were accidental extubations (2.6/100 ventilator days). CIs were most often precipitated by consultants (32 %), followed by residents (23 %, over-represented in drug CIs, 22/62) and specialized nurses (21 %). Doctors had a greater proportion of major CIs than nurses (p < 0.01). Fifty percent of the CIs were detected by routine checks. The most important method of detection was patient inspection (44 %), alarms accounted for only 10 %. Contributing factors were human errors (63 %), communication failure (14 %), organizational problems (10 %), equipment dysfunction (7 %) and milieu (3 %).¶Conclusion: CIs are very common in pediatric intensive care. Knowledge of them is a precious source for quality improvement through changes in the system.     

The "New Look" approach to patient safety: a guide for clinical nurse specialist leadership

This article describes a complex system model based on human performance factors that is borrowed from other industries but can be used by clinical nurse specialists for making progress in patient safety. Traditional approaches to investigation and follow-up of errors in healthcare organizations have not resulted in improvement in patient safety. The New Look approach described in this article emphasizes the complexity in which healthcare workers make decisions about patient c are every day and how increased learning about the resiliency of healthcare workers in the face of multiple system gaps and discontinuities will lead to long-lasting improvements in safety. The article describes how the clinical nurse specialist can lead efforts using the New Look human performance-based approach in 4 areas: changing to a nonpunitive culture, learning about system complexity, learning about healthcare worker resiliency, and preparing for the complexity of introducing change.     

Concept analysis of nurse retention

Nurse retention is widely acknowledged as a crucial international workforce issue, yet the concept remains ambiguous. This study focuses on a concept analysis in an effort to clarify the attributes of nurse retention, including its antecedents and consequences. The Walker and Avant approach was applied to analyze the concept of nurse retention. Four key attributes of nurse retention were identified in the analysis, specifically motivation, intention, and individual decision; strategy and intervention; geographic context; and attachment to work. Antecedents of nurse retention included the healthcare system at the macro level, the health care facility, health personnel, and living conditions. Retention has consequences for individual nurses, the healthcare organization, and the overall health system. Our concept analysis provides clarification to better understand nurse retention along with its implications for the healthcare workforce. The analysis further emphasizes the importance of retention as a comprehensive priority issue for human resources when recruiting and maintaining the nursing workforce internationally.     

虚拟现实系统中岩骨颞下和乙状窦前入路比较研究

目的 在虚拟现实系统中评估比较颞下和乙状窦前入路磨除岩骨显露解剖结构的顺序和范围.方法 将尸体头颅CT影像数据输入Dextroscope虚拟现实系统,构建岩骨三维解剖模型.分别模拟颞下和乙状窦前入路磨除岩骨并测量数据.结果颞下入路和乙状窦前入路磨除岩骨的虚拟现实可视化效果良好,解剖数据测量方便快捷;膝状神经节和乳突尖部分别为颞下入路和乙状窦前入路的重要术中解剖标志;乙状窦前入路显露岩骨内结构的磨除骨质操作多于颞下入路,显露颈静脉球受到岩骨内其他结构遮挡少于颞下入路;颞下入路显露颈内动脉所受岩骨内其他结构遮挡少于乙状窦前入路.结论 颞下入路适合显露颈内动脉,乙状窦前入路在显露颈静脉孔区方面具有优势.虚拟现实系统在同一模型中进行不同入路模拟,有利于节约标本,进行个体化比较.     

Moral competence in nursing practice

This article presents the derivation of moral competence in nursing practice by identifying its attributes founded on Thai culture. In this process moral competence is formed and based on the Thai nursing value system, including personal, social and professional values. It is then defined and its three dimensions (moral perception, judgment and behavior) are also identified. Additionally, eight attributes as indicators of moral competence are identified and selected from three basic values. The eight attributes are loving kindness, compassion, sympathetic joy, equanimity, responsibility, discipline, honesty, and respect for human values, dignity and rights. All attributes are discussed by addressing the three moral dimensions in order to present how to deal with ethical issues in nursing practice. As a summary, a model of moral competence is presented to demonstrate moral competence in nursing practice in Thailand.