医疗不良事件与系统问题相关因素的分析

目的:通过对医疗不良事件中能够发现的显性失误和内在隐性因素进行分析和总结,对系统问题进行详细而深入的剖析,改进系统和流程,使医疗风险管理更具有科学性和有效性。方法:针对在2003-2006年期间发生的35起医疗不良事件进行分析和总结。结果:经分析发现,引发医疗不良事件的因素主要是系统错误。结论:绝大多数医疗不良事件的发生是因系统和流程隐患造成的,个人因素只是其中较少的一部分。因此,应通过加强医疗事故处理管理和病人安全管理,改进医疗系统和流程,减小和防范医疗风险的发生。

Medical adverse event and related factors of systematic problem

Objective：To analyze the obvious mistake and covert systematic factors related to medical adverse event,then improve systematic workflow to manage medical risk scientifically and effectively.Methods：We analyzed 35 cases of adverse medical events between 2003 and 2006.Results：The primary factor related to adverse medical events was systematic error.Conclusion：Most medical adverse events were caused by systematic problems.Individual factor was only small part of the causes.Improving medical system workflow and enhancing management of medical adverse events were thus very needed to prevent medical risk problems.