Wechat logo 50 41 d4bae92fc2b9067675bfee08d2b00834882415940f50456376420c2e77a679ac
返回

Human Error in Perspective


FDA Patient Safety News - March, 2002 - Show #2 The FDA is spotlighting the "patient safety movement" and reports on the large estimate of patient deaths due to medical error.

点击高亮查看翻译

Mark Barnett, Communications Director, FDA: We also want to call your attention to an interesting article by Doctors Charles Billings and David Woods in the January 2001 issue of Postgraduate Medicine. It's called "Human Error in Perspective". The article starts out with a little history of the so-called "patient safety movement", including the influence of the famous report of the Institute of Medicine in 1999, with its disturbingly large estimate of patient deaths due to medical error. The article then goes on to stress that it's not enough to attribute the cause of an adverse event to "human error". Here's what they say: "Attributing adverse events to human error is too often the final step in the investigation, when in fact it should be simply the first step in understanding how and why such failures occur." They close the article with five prescriptions for success in achieving patient safety:
AR: First, recognize that failures can and will happen in any system: no one is immune. Look for and find the vulnerabilities in your system through purposeful, interdisciplinary effort.
MB: Second, understand the problem before you fix it. Applying apparent solutions before you understand the many facets of a problem ensures failure.
AR: Third, fix the whole system, not just the immediate problem. Chalking an incident up simply to "human error" will give you an incorrect, incomplete or shallow explanation.
MB: Fourth, simplify, don't complicate. Make it easier for people to do it right, and harder for them to do it wrong. Simplifying the operation of a system can dramatically improve its reliability by making it easier for the humans in the system to operate effectively.
AR: And fifth, instead of blaming people, help them to do it better. The authors close the article by saying that the most effective prescription for healthcare system improvement is to support people as they perform their day-to-day tasks.

  • Sound e31a43d441998f862b764d17930467a5a23de45c433219259bed5eb42e3a7615
    adverse event 不良事件; 不良反应◆【略】AE
  • Sound e31a43d441998f862b764d17930467a5a23de45c433219259bed5eb42e3a7615
    apparent solution 显而易见的解决办法 ;表面上的解决办法
  • Sound e31a43d441998f862b764d17930467a5a23de45c433219259bed5eb42e3a7615
    article 文章【名词】1. 物品;制品,商品; 2. 项目,条款; 3. 【动物;动物学】节; 4. (报章杂志中的)文章,论文; 5. 【语法】冠词; 6. (古语)(之)际,刹那; 7. (俚语)人,家伙; 【及物动词】1. 把…逐条登载,分条解释; 2. 列举(罪状);控告; 3. 用条款约束;定契约把…收为学徒; 【不及物动词】1. 订契约; 2. 约定
  • Sound e31a43d441998f862b764d17930467a5a23de45c433219259bed5eb42e3a7615
    attribute 【名词】1. 属性,特质 2. (人物、官职等的)标志,表征 3. 【语法】属性形容词 【及物动词】1. 认为…属于 2. 把…归因于 3.确定…产生的时间、时期或地点
  • Sound e31a43d441998f862b764d17930467a5a23de45c433219259bed5eb42e3a7615
    Attributing Adverse Events to Human Error 把不良事件归咎于人为的错误◆【略】AE
  • Sound e31a43d441998f862b764d17930467a5a23de45c433219259bed5eb42e3a7615
    author 作者【名词】1. 著者,作家; 2. 著作物,作品; 3. 创造者;发起人; 【及物动词】1. 写,写作; 2. 创造,创始; 3. 【自动化】(在计算机上)制作(网页)
  • Sound e31a43d441998f862b764d17930467a5a23de45c433219259bed5eb42e3a7615
    billing 计费【名词】1. (节目单、剧院门口华盖等上的)演员表; 2. (演员表上的)演员名次
  • Sound e31a43d441998f862b764d17930467a5a23de45c433219259bed5eb42e3a7615
    blame 责备【名词】1. 责怪,责备,非难,指责;挑剔;谴责; 2. 过失,过错,罪,咎;责;责任; 【及物动词】1. 责备,谴责,非难,挑剔; 2. 把…归咎于,怪在…头上 (on upon)
  • Sound e31a43d441998f862b764d17930467a5a23de45c433219259bed5eb42e3a7615
    call your attention 提醒你注意
  • Sound e31a43d441998f862b764d17930467a5a23de45c433219259bed5eb42e3a7615
    cause of an adverse event 造成不良事件的原因◆【略】AE
  • chalk 【名词】粉笔 ,白垩 ,记录; 【形容词】用粉笔写的 ,[美俚语]【赛马】最有希望获胜的 ,【及物动词】用粉笔写 ,做记号 ,使变苍白; 【不及物动词】变成粉末状
  • Sound e31a43d441998f862b764d17930467a5a23de45c433219259bed5eb42e3a7615
    chalking an incident up simply to "human error" 把一个事件简单地归咎于“人为”
  • Sound e31a43d441998f862b764d17930467a5a23de45c433219259bed5eb42e3a7615
    Communications Director 通信负责人;外联主管; 新闻负责人
  • Sound e31a43d441998f862b764d17930467a5a23de45c433219259bed5eb42e3a7615
    complicate 【动词】使复杂; 使麻烦
  • Sound e31a43d441998f862b764d17930467a5a23de45c433219259bed5eb42e3a7615
    day-to-day task 日常事务
  • Sound e31a43d441998f862b764d17930467a5a23de45c433219259bed5eb42e3a7615
    director 主管【名词】1. 指挥者,监督人,管理人; 总监;院长;所长;主任 2.理事,董事;经理 3. 【戏剧】导演【音乐】指挥 4. 引向器; 指示器; 导向偶极子
  • Sound e31a43d441998f862b764d17930467a5a23de45c433219259bed5eb42e3a7615
    disturbingly large estimate of patient deaths 惊人大的患者死亡估算
  • Sound e31a43d441998f862b764d17930467a5a23de45c433219259bed5eb42e3a7615
    due to medical error 由于医疗过失
  • Sound e31a43d441998f862b764d17930467a5a23de45c433219259bed5eb42e3a7615
    effective 有效【形容词】1. 有效(力)的,灵验的;显眼的,(美国)生效的,被实施的;【军事】有战斗力的; 2. 【经济学】实质上的;有实价的; 3. 【军事】精锐的
  • Sound e31a43d441998f862b764d17930467a5a23de45c433219259bed5eb42e3a7615
    effectively 有效【副词】1. 有效地,有力地; 2. 实际上
  • Sound e31a43d441998f862b764d17930467a5a23de45c433219259bed5eb42e3a7615
    Error in Perspective 错误的观点
  • Sound e31a43d441998f862b764d17930467a5a23de45c433219259bed5eb42e3a7615
    estimate 估计 【及物动词】1. 估计,估算;估价;估量; 2. 评价,评断; 3. (古语)尊重; 【不及物动词】估计,估价; 【名词】1. 估计; 预测;(英国) (pl.)预算,预算额;预算书;估价单;(从典型统计得出的)数值; 2. 评价,判断
  • Extracting Microarray Gene Expression Patterns and Identifying co-expressed Genes 提取微阵列基因表达模式和确认共表达基因◆【略】EPIG
  • Sound e31a43d441998f862b764d17930467a5a23de45c433219259bed5eb42e3a7615
    facets 方面【解剖学】(骨或其他硬部位的)小(平)面 【动物学】(昆虫的)小眼面
  • Sound e31a43d441998f862b764d17930467a5a23de45c433219259bed5eb42e3a7615
    failure 失败【名词】衰竭,失效,故障,失灵,破坏,衰,失败者,失误
  • Sound e31a43d441998f862b764d17930467a5a23de45c433219259bed5eb42e3a7615
    final step in the investigation 调查的最后一步
  • Sound e31a43d441998f862b764d17930467a5a23de45c433219259bed5eb42e3a7615
    finding 【名词】1.发现,发现物,调查的结果,研究结果; 2. 裁决,定罪 【动词原形】find
  • Sound e31a43d441998f862b764d17930467a5a23de45c433219259bed5eb42e3a7615
    fixed 固定【形容词】1. 固定的;确定的,不变的,固执的; 2. 【化学】凝固的,不易挥发的; 3. (美口)(在经济上)处境…的; 4. (美俚)(比赛等)通过作弊预先安排好结果的
  • Sound e31a43d441998f862b764d17930467a5a23de45c433219259bed5eb42e3a7615
    healthcare 医疗保健;医疗卫生;健康服务
  • Sound e31a43d441998f862b764d17930467a5a23de45c433219259bed5eb42e3a7615
    healthcare system 医疗保健系统
  • Sound e31a43d441998f862b764d17930467a5a23de45c433219259bed5eb42e3a7615
    healthcare system improvement 医疗体系的改进
  • Sound e31a43d441998f862b764d17930467a5a23de45c433219259bed5eb42e3a7615
    human error 人为错误
  • Sound e31a43d441998f862b764d17930467a5a23de45c433219259bed5eb42e3a7615
    immediate problem 眼前的问题
  • Sound e31a43d441998f862b764d17930467a5a23de45c433219259bed5eb42e3a7615
    immune 免疫【形容词】1. 免疫(性)的; 2. 有免疫力的,可避免的; 3. 免除(税等)的; 4. 不受影响的
  • Sound e31a43d441998f862b764d17930467a5a23de45c433219259bed5eb42e3a7615
    incident 【名词】1. 事件,事变;插曲 2. 【法律】财产所附带的权利[义务];【形容词】1. 附带的,伴随的,必然的 2. 【法律】附带的; 3. 入射的
  • Sound e31a43d441998f862b764d17930467a5a23de45c433219259bed5eb42e3a7615
    incorrect, incomplete or shallow explanation 错误的, 不完整的或肤浅的解释
  • Sound e31a43d441998f862b764d17930467a5a23de45c433219259bed5eb42e3a7615
    institute 研究所【名词】1. 协会,学会;学院,专科大学;(学院附设的)研究所; 2. 讲习会;(短期)训练班; 3. 会址,院址,校址,所址; 4. 原则,规则,惯例; 5. (给初学者用的法律、医学等的)浅说,(公认的)基本原理; 【及物动词】1. 设,设立,制定; 2. 实行,创立,开始; 3. 任命,【宗教】授…以圣职
  • Sound e31a43d441998f862b764d17930467a5a23de45c433219259bed5eb42e3a7615
    Institute of Medicine 医学学院
  • Sound e31a43d441998f862b764d17930467a5a23de45c433219259bed5eb42e3a7615
    interest 利益【名词】兴趣,利息,感兴趣,权益,利率,趣味,关注,关心,爱好
  • Sound e31a43d441998f862b764d17930467a5a23de45c433219259bed5eb42e3a7615
    interesting article 有趣的文章
  • Sound e31a43d441998f862b764d17930467a5a23de45c433219259bed5eb42e3a7615
    investigation 1. 调查研究,调查,研究,调查,审查;2. 研究论文,调查报告
  • Sound e31a43d441998f862b764d17930467a5a23de45c433219259bed5eb42e3a7615
    many facets of a problem 一个问题的许多方面
  • Sound e31a43d441998f862b764d17930467a5a23de45c433219259bed5eb42e3a7615
    marking 标识【名词】1. 作记号;记分;记号,印记,点;(尤指鸟兽的皮、羽毛等的)斑纹,条纹; 2. 【商业】(支票的)认付; 【形容词】赋与特征的,使显眼的
  • Sound e31a43d441998f862b764d17930467a5a23de45c433219259bed5eb42e3a7615
    medical error 医疗过失
  • Sound e31a43d441998f862b764d17930467a5a23de45c433219259bed5eb42e3a7615
    most effective prescription 最有效的解决方法
  • movement 运动【名词】动作,移动,机芯,乐章,动静,流动,运行,活动,动
  • Sound e31a43d441998f862b764d17930467a5a23de45c433219259bed5eb42e3a7615
    patient death 患者死亡
  • Sound e31a43d441998f862b764d17930467a5a23de45c433219259bed5eb42e3a7615
    patient safety 患者的安全
  • Sound e31a43d441998f862b764d17930467a5a23de45c433219259bed5eb42e3a7615
    perspective 观点【名词】视角,透视,角度,角度来看,透视图,视野,前景,展望,看法
  • Sound e31a43d441998f862b764d17930467a5a23de45c433219259bed5eb42e3a7615
    Postgraduate Medicine 外国杂志名称(研究生医学)
  • Sound e31a43d441998f862b764d17930467a5a23de45c433219259bed5eb42e3a7615
    prescription 【名词】1. 处方;处方的药;解救方法 2. 命令;规定;法规 3.【法律】(由于长期使用等而)获得权利 【形容词】按处方配制的◆【対】over-the-counter (OTC)
  • Sound e31a43d441998f862b764d17930467a5a23de45c433219259bed5eb42e3a7615
    prescriptions for success 成功的解决办法
  • Sound e31a43d441998f862b764d17930467a5a23de45c433219259bed5eb42e3a7615
    purposeful, interdisciplinary effort 有目的, 跨学科的努力
  • Sound e31a43d441998f862b764d17930467a5a23de45c433219259bed5eb42e3a7615
    reliability 可靠性【名词】可靠性,安全性,确实(性)
  • Sound e31a43d441998f862b764d17930467a5a23de45c433219259bed5eb42e3a7615
    rights [法] 权利;权限;权益 [All rights reserved] 版权所有
  • Sound e31a43d441998f862b764d17930467a5a23de45c433219259bed5eb42e3a7615
    so-called 【形容词】所谓的;号称的(常含贬义)
  • Sound e31a43d441998f862b764d17930467a5a23de45c433219259bed5eb42e3a7615
    so-called 'patient safety movement' 所谓的"患者安全运动"
  • Sound e31a43d441998f862b764d17930467a5a23de45c433219259bed5eb42e3a7615
    solution 解决方案【名词】1. 溶解;溶液,溶体,溶剂; 2. (补轮胎用的)橡胶水;(美国)药水; 3. 解决,解答; 解释;(数学等的)解法,解式; 4. 免除,解除; 5.【医学】消散,消退
  • Sound e31a43d441998f862b764d17930467a5a23de45c433219259bed5eb42e3a7615
    stress 应力【名词】压力,应激,胁迫,受力,重音,紧张
  • success 成功【名词】取得成功,成功与否,成就,成败,成功率,胜利,成绩
  • Sound e31a43d441998f862b764d17930467a5a23de45c433219259bed5eb42e3a7615
    vulnerability 脆弱性;易损性;弱点
Sound e31a43d441998f862b764d17930467a5a23de45c433219259bed5eb42e3a7615