IF 3.4 3区 医学 Q1 EMERGENCY MEDICINE Academic Emergency Medicine Pub Date : 2025-03-03 DOI:10.1111/acem.15076
Meagan M Ladell, Nancy L Jacobson, Sarah C Yale, Katie L McDermott, Elizabeth L Papautsky, Kenneth R Catchpole, Matthew C Scanlon
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引用次数: 0

摘要

长期以来,调查医疗保健中的差错一直是患者安全工作的核心重点,然而这种方法过度简化了一个相互关联、充满活力的系统的复杂性。本文认为,将对患者造成的伤害仅仅归结为 "错误 "并不能带来有意义的改善,因为它忽略了导致不良后果的更广泛因素。通过一个案例研究,我们说明了只关注错误调查如何错过了关键的洞察力,并提出应将注意力转向识别和管理危害。我们强调将医疗保健视为社会技术系统的重要性,主张应用社会技术系统思维,尤其是在解决急诊医学等高压环境下的诊断错误时。传统的方法,如根本原因分析、错误调查和瑞士奶酪模型,已不再足够。这些过时的框架无法应对临床医生所面临的系统性挑战,往往会误导安全干预措施。本文呼吁转变模式,利用人为因素研究重新设计医疗保健系统,以更好地适应临床工作的复杂性和导致伤害的危险。
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The problem with how we view medical (and diagnostic) error in emergency medicine.

Investigating error in healthcare has long been a central focus of patient safety efforts, yet this approach oversimplifies the complexities of a deeply interconnected and dynamic system. This paper argues that framing patient harm solely as "error" has failed to yield meaningful improvements, as it overlooks the broader factors contributing to adverse outcomes. Through a case study, we illustrate how an exclusive focus on error investigation missed critical insights and propose that attention should instead be directed towards identifying and managing hazards. Emphasizing the importance of treating healthcare as a sociotechnical system, we argue for the application of sociotechnical system thinking, particularly in addressing diagnostic errors in high-pressure environments like emergency medicine. The traditional methods, such as root cause analysis, error investigation, and the Swiss cheese model, are no longer sufficient. These outdated frameworks fail to address the systemic challenges clinicians face and often misguide safety interventions. The paper calls for a paradigm shift towards re-designing healthcare systems using human factors research to better align with the complexities of clinical work and the hazards that lead to harm.

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来源期刊
Academic Emergency Medicine
Academic Emergency Medicine 医学-急救医学
CiteScore
7.60
自引率
6.80%
发文量
207
审稿时长
3-8 weeks
期刊介绍: Academic Emergency Medicine (AEM) is the official monthly publication of the Society for Academic Emergency Medicine (SAEM) and publishes information relevant to the practice, educational advancements, and investigation of emergency medicine. It is the second-largest peer-reviewed scientific journal in the specialty of emergency medicine. The goal of AEM is to advance the science, education, and clinical practice of emergency medicine, to serve as a voice for the academic emergency medicine community, and to promote SAEM''s goals and objectives. Members and non-members worldwide depend on this journal for translational medicine relevant to emergency medicine, as well as for clinical news, case studies and more. Each issue contains information relevant to the research, educational advancements, and practice in emergency medicine. Subject matter is diverse, including preclinical studies, clinical topics, health policy, and educational methods. The research of SAEM members contributes significantly to the scientific content and development of the journal.
期刊最新文献
Global emergency medicine: A scoping review of the literature from 2023. The problem with how we view medical (and diagnostic) error in emergency medicine. Response to Tangkamolsuk and La RE: Online public response to emergency department diagnostic error report: A qualitative study. Abortion care in the emergency department: A national survey of emergency physicians' perspectives. Implementation and assessment of a one-month sabbatical program for faculty in an academic emergency department.
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