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首页> 外文期刊>BMJ quality & safety >Early warnings, weak signals and learning from healthcare disasters
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Early warnings, weak signals and learning from healthcare disasters

机译：预警，信号微弱以及从医疗灾难中学习

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In the wake of healthcare disasters, such as the appalling failures of care uncovered in Mid Staffordshire, inquiries and investigations often point to a litany of early warnings and weak signals that were missed, misunderstood or discounted by the professionals and organisations charged with monitoring the safety and quality of care. Some of the most urgent challenges facing those responsible for improving and regulating patient safety are therefore how to identify, interpret, integrate and act on the early warnings and weak signals of emerging risks - before those risks contribute to a disastrous failure of care. These challenges are fundamentally organisational and cultural: they relate to what information is routinely noticed, communicated and attended to within and between healthcare organisations - and, most critically, what is assumed and ignored. Analysing these organisational and cultural challenges suggests three practical ways that healthcare organisations and their regulators can improve safety and address emerging risks. First, engage in practices that actively produce and amplify fleeting signs of ignorance. Second, work to continually define and update a set of specific fears of failure. And third, routinely uncover and publicly circulate knowledge on the sources of systemic risks to patient safety and the improvements required to address them.
机译：在发生医疗灾难之后，例如在斯塔福德郡中部发生的令人震惊的医疗失误，调查和调查通常指向一连串的预警和信号微弱，而负责监视安全的专业人员和组织则错过，误解或轻视了这些预警和信号和护理质量。因此，负责改善和调节患者安全的人员所面临的一些最紧迫的挑战是，如何识别，解释，整合新的风险的预警和微弱信号并采取行动，以防这些风险导致灾难性的医疗失败。这些挑战从根本上讲是组织上和文化上的：它们与医疗机构内部和之间的例行注意，传达和关注的信息有关，最关键的是，假定和忽略了什么。分析这些组织和文化方面的挑战，提出了三种切实可行的方法，使医疗保健组织及其监管机构可以提高安全性并应对新出现的风险。首先，请采取能积极产生和扩大短暂的无知迹象的做法。第二，努力不断定义和更新一系列对失败的特定恐惧。第三，定期发现并公开传播有关患者安全的系统性风险来源以及解决这些风险所需的改进措施的知识。

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