临床护理作业中医疗人因失误的诱发因素、机理及防范研究

Medical human error is an important social issue related to patient safety. There are many unresolved issues in research on errors, such as incomplete analysis of medical operation characteristics, imperfect extraction of error factors, and insufficient identification of error-induced mechanisms, which impede error analysis and error prevention. To address these issues, this project focused on medical human errors during clinical nursing operation, including deep analysis of medical operation characteristics and a microcosmic overview of medical human errors firstly. Second, we extracted medical human error factors through related case analysis, then we established a multi-level, incremental medical error system with both generality for multiple domains and specificity for a given domain. Third, for complex medical operation, we not only consider multidimensional factors but also analyze coupling effects and the distribution of weights. Then, we discuss the error induction mechanism, considering multidimensional factors according to quantitative model building techniques. Finally, we construct an intelligent medical human factor analysis technique platform for prevention of medical human error, and a medical operation process optimization method based on the above results is developed. A series of recommendations are made to medical institutions to verify the availability and effectiveness of the conclusions.

医疗人因失误关系到每一患者安全，是重要的社会课题。目前医疗人因失误相关研究中存在着对医疗作业特征剖析不充分、对人因失误诱发因素提取不全面、对人因失误诱发机理解析不清晰等问题，从而阻碍着医疗人因失误分析与失误防范。针对上述问题本项目以临床护理作业中的医疗人因失误为研究对象，首先从微观角度深度剖析医疗作业特征、概览医疗人因失误全貌。其次，通过分析大量医疗人因失误案例全方位提取医疗人因失误因素并建立包含多领域通用型与医疗领域特殊型的多层次渐进式的医疗人因失误体系。再次，针对复杂医疗作业情境不仅考虑多维因素且进一步解析多维因素间的耦合效应与权重分配问题，并基于定量模型构建技术研究考虑多维因素的医疗人因失误诱发机理。最后，面向医疗人因失误防范基于上述研究成果构建智能化医疗人因失误分析技术平台、开发医疗作业流程优化方法，并将一系列研究成果应用于实际医疗机构，验证研究成果的可用性与有效性。

临床护理作业是一个伴随着紧急性、个别性、多样性与多变性的与患者安全密切相关的高压高负荷作业，其复杂作业特征诱发的医疗人因失误是学术研究热点问题与失误防范重要对象。针对上述问题本项目首先以临床护理作业中的医疗人因失误为研究对象，从宏观与微观角度深度剖析了医疗作业特征、概览了医疗人因失误类型的全貌。其次通过大量医疗人因失误案例分析提取了体现医疗作业特征的失误模式、组织因素与作业情境因素，并研究了它们间的关联机制。然后针对人因失误因素提取对分析者专业背景要求较高、分析所需时间较长等问题，根据医疗人因失误中各变量的特点选择支持向量机理论提出了一种从失误内容中辨识出医疗人因失误因素的技术。最后以医疗器械为例开发了人因可靠性评估方法并进行了实际案例的应用。研究成果有效阐述了医疗人因失误发生的内在机制与规律，达到对医疗人因失误发生机理的全方位精准解析。它不仅补充与完善了医疗中人因失误相关的理论与方法，而且具有具体性高、医疗针对性强等特征，可直接指导于实际医疗场景，在医疗人因失误分析与防范方面具有较高研究意义。

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