WHO全球患者安全联盟

介绍了全球患者安全工作现状、WHO全球患者安全联盟的发展历程;总结和分析了患者安全联盟面临的任务与挑战.     

患者安全与医疗系统的持续改进

20世纪90年代以来,患者安全的问题受到世界各国的重视,国际上几个探讨医疗错误的大规模流行病学研究所,特别是1999年美国医学研究所发表了著名的报告--"错误凡人皆有:构建一个更安全的卫生系统,"揭露了在目前的医疗环境中存在的相当程度的医疗错误与风险.本文概述了全球面临患者安全问题的挑战;应对患者安全挑战的国内外动态;以及安全医疗环境的建立应该妥善处理个人责任与管理系统原因的关系,摈弃苛责个人的文化而以系统改善为导向的思考;最后就促进医疗质量和患者安全的持续改进提出了建议.     

Patient safety in radiology: Our experience

BackgroundPresent-day radiology departments have very high footfall of patients and are prone to patient safety errors. This study analyses such errors in our hospital.MethodsObservational cross-sectional analysis of errors over the last 30 months was performed. These were classified using the Eindhoven classification model into technical, organizational, and human errors. Technical errors focused on equipment safety. Organizational errors related to policies. Human errors were subclassified as per the skill rule knowledge model. Root cause analysis was performed wherever necessary, and possible mitigation strategies for ensuring safety were suggested. Errors peculiar to the Armed Forces environment were specifically addressed.ResultsSeventy-seven errors were analyzed. Two were equipment based including faulty pressure injector syringes and radiation leakage from the computed tomography gantry. Of 44 skill-based errors, 09 involved dispatch of wrong reports to dependents owing to identifying patients with serving personnel's name. Four were due to scanning wrong sites. Eleven involved reporting abnormality on the wrong side. Six involved underreporting due to not viewing specific images. The rest were due to failure to omit conflicting elements in the report. Rule-based errors included wrong protocol selection (9 errors), omitting a particular sequence due to individual preference (6 errors), and so on. Knowledge-based errors were due to misinterpretation of findings (4 errors), reporting an abnormality as normal (3 errors), and selection of wrong modality (3 errors).ConclusionThe findings of this study highlights the importance of voluntary reporting, diligent recording, and in-depth analysis of errors for understanding the causes and formulating possible mitigation strategies.