Subscribe to RSS
DOI: 10.1055/s-2001-14806
Patientensicherheit und Fehler
in der Medizin
Entstehung, Prävention und Analyse von ZwischenfällenPatient Safety and Errors in Medicine: Development, Prevention and Analyses of Incidents
Publication History
Publication Date:
31 December 2001 (online)
![](https://www.thieme-connect.de/media/ains/200106/lookinside/thumbnails/10.1055-s-2001-14806-1.jpg)
Zusammenfassung.
Die Patientensicherheit und Fehler in der Medizin rücken zunehmend in das öffentliche Interesse. Nach neuen Untersuchungen sind medizinische Fehler unter den zehn häufigsten Todesursachen. Eine neue Welle der Beschäftigung mit Fehlern und deren Ursachen auf der Systemebene des Gesundheitswesens hat begonnen. Das Fachgebiet der Anästhesiologie gilt dabei als Vorbild im Bemühen um eine systematische Erhöhung der Patientensicherheit. Dies ist Auszeichnung und Auftrag zugleich. In anderen Hochrisikobereichen mit hohem Anspruch an Systemsicherheit (Kernkraft, Flugsicherheit) haben sich zahlreiche Strategien zur Erhöhung der Sicherheit bewährt. Es scheint an der Zeit, diese Strategien für die Anwendung im Bereich der Medizin zu überprüfen und gegebenenfalls entsprechend anzupassen und umzusetzen. Hierzu gehören die Vermittlung der Kenntnis, wie Fehler in komplexen Systemen entstehen und welche Fehlerarten es gibt; die Einführung von Erfassungssystemen für unerwünschte Ereignisse, die frei von negativen Konsequenzen für die Berichtenden sein müssen; die Förderung der kontinuierlichen Ausbildung und die Entwicklung von allgemeinen Problemlösekompetenzen und schließlich der größtmögliche Einsatz von Trainingssimulatoren. Wichtigster Faktor zur langfristigen Erhöhung der Patientensicherheit ist aber ein „Kulturwandel”. Diese Kultur der personenbezogenen Verurteilung („Culture of Blame”), sollte einer offenen Sicherheitskultur („Safety Culture”) weichen, die Fehler und Zwischenfälle als Problem des Gesamtsystems sieht. Das Akzeptieren der menschlichen Fehleranfälligkeit und die offene Analyse von Fehlern ohne persönliche Schuldzuweisungen, im Sinne einer „präventiven Fehlerkultur”, sollte dann auch zu Lösungen auf Systemebene führen. Dieser Kulturwandel kann nur mit hohem Engagement von höchster Ebene vollzogen werden, indem Patientensicherheit explizit zum höchsten Ziel erklärt werden: „Primum nihil nocere” - „Das Wichtigste ist: Schade nicht”.
Patient Safety and Errors in Medicine: Development, Prevention and Analyses of Incidents.
“Patient safety” and “errors in medicine” are issues gaining more and more prominence in the eyes of the public. According to newer studies, errors in medicine are among the ten major causes of death in association with the whole area of health care. A new era has begun incorporating attention to a “systems” approach to deal with errors and their causes in the health system. In other high-risk domains with a high demand for safety (such as the nuclear power industry and aviation) many strategies to enhance safety have been established. It is time to study these strategies, to adapt them if necessary and apply them to the field of medicine. These strategies include: to teach people how errors evolve in complex working domains and how types of errors are classified; the introduction of critical incident reporting systems that are free of negative consequences for the reporters; the promotion of continuous medical education; and the development of generic problem-solving skills incorporating the extensive use of realistic simulators wherever possible. Interestingly, the field of anesthesiology - within which realistic simulators were developed - is referred to as a model for the new patient safety movement. Despite this proud track record in recent times though, there is still much to be done even in the field of anesthesiology. Overall though, the most important strategy towards a long-term improvement in patient safety will be a change of “culture” throughout the entire health care system. The “culture of blame” focused on individuals should be replaced by a “safety culture”, that sees errors and critical incidents as a problem of the whole organization. The acceptance of human fallability and an open-minded non-punitive analysis of errors in the sense of a “preventive and proactive safety culture” should lead to solutions at the systemic level. This change in culture can only be achieved with a strong commitment from the highest levels of an organization. Patient safety must have the highest priority in the goals of the institution: “Primum nihil nocere” - “First, do not harm”.
Schlüsselwörter:
Sicherheitskultur - Zwischenfälle - CRM Crisis Resource Management
Key words:
Safety Culture - Critical incidents - CRM
Literatur
- 1 Berwick D M L. Reducing errors in medicine (editorial). BMJ. 1999; 319 136-137
- 2 Weingart S N, Wilson R M, Gibberd R W, Harrison B. Epidemiology of medical error. BMJ,. 2000; 320 774-777
- 3 Kohn L T, Corrigan J M, Donaldson M S. To Err is Human - Building a Safer Health System. National Academy Press, Washington 1999
- 4 Reinertsen J L. Let's talk about error [editorial]. BMJ.. 320; 2000 730
- 5 Reducing error - Improving safety. BMJ 2000 320
- 6 Gaba D M. Anaesthesiology as a model for patient safety in health care. BMJ,. 2000; 320 785-788
- 7 Leape L L. Error in medicine (see comments). JAMA.. 1994; 272 1851-1857
- 8 Decker K, Rall M. Simulation in anaesthesia: a step towards improved patient safety. Min Invas Ther & Allied Technol.. 2000; 9 325-332
- 9 Cooper J B, Newbower R S, Long C D, McPeek B. Preventable anesthesia mishaps: a study of human factors. Anesthesiology. 1978; 49 399-406
- 10 Cooper J B. Toward prevention of anesthetic mishaps. Int Anesthesiol Clin.. 1984; 22 167-183
- 11 Cooper J B, Newbower R S, Kitz R J. An analysis of major errors and equipment failures in anesthesia management: considerations for prevention and detection. Anesthesiology. 1984; 60 34-42
- 12 Cooper J B. Gaba DM. A strategy for preventing anesthesia accidents. Int Anesthesiol Clin. 1989; 27 148-152
- 13 Gaba D M, Maxwell M, DeAnda A. Anesthetic mishaps: breaking the chain of accident evolution. Anesthesiology. 1987; 66 670-676
- 14 Webb R K, Currie M, Morgan C A, Williamson J A, Mackay P, Russell W J, Runciman W B. The Australian Incident Monitoring Study: an analysis of 2000 incident reports. Anaesth Intensive Care. 1993; 21 520-528
- 15 Williamson J A, Webb R K, Sellen A, Runciman W B, Van der Walt J H. The Australian Incident Monitoring Study. Human failure: an analysis of 2000 incident reports. Anaesth Intensive Care,. 1993; 21 678-683
- 16 Gaba D M, DeAnda A. A comprehensive anesthesia simulation environment: re-creating the operating room for research and training. Anesthesiology. 1988; 69 387-394
- 17 Gaba D M. DeAnda A. The response of anesthesia trainees to simulated critical incidents. Anesth Analg,. 1989; 68 444-451
- 18 Gaba D M. The human work environment and anesthesia simulators. Miller, R.D., ed In Anesthesia, Churchill-Livingstone, Philadelphia 2000
- 19 Maurino D E, Reason J, Johnston N, Lee R B. Beyond Aviation Human Factors. Ashgate, Aldershot 1995
- 20 Norman D A. The Psychology of Everyday Things. BasicBooks 1988
- 21 Perrow C. Normal Accidents. Princeton University Press, Princeton 1999
- 22 Reason J. Human error. Cambridge 1994
- 23 Reason J. Managing the Risks of Organizational Accidents. Ashgate, Aldershot 1997
- 24 Hartmannsgruber & Good .Anesthesia simulators and training devices. Anaesthesist 1993
- 25 Morell C M. Erickson JI. Patient Safety in Anesthetic Practice. Churchill-Livingstone, New York 1997
-
26 Weizsäcker von C, Weizsäcker von E U.
Fehlerfreundlichkeit. Kornwachs, K., ed In Offenheit - Zeitliche Komplexität. Zur Theorie offener Systeme. Campus, Frankfurt 1985 - 27 Nolan T W. System changes to improve patient safety. BMJ. 2000; 320 771-773
- 28 Norman D A. Things that make us smart. Perseus Books, Reading, MA 1993
- 29 Wehner T. Sicherheit als Fehlerfreundlichkeit. Westdeutscher Verlag, Opladen 1992
- 30 Weizsäcker von C, Weizsäcker von E U. Fehlerfreundlichkeit als evolutionäres Prinzip. Wechselwirkung. 1986; 29 12-15
- 31 Rasmussen J. Skills, rules, knowledge: signals, signs and symbols and other distinctions in human performance models. IEEE TRANSACTIONS ON SYSTEMS MAN AND CYBERNETICS. 1983; SMC-13 257-267
- 32 Rall M. Anmerkungen des Übersetzers. In Zwischenfälle in der Anästhesie. Prävention und Management. Gustav Fischer, Lübeck 1998
- 33 Reason J. Human error: models and management. BMJ. 2000; 320 768-770
- 34 Vaughan D. The Challenger Launch Decision. The University of Chicago Press, Chicago 1996
- 35 Kluwe R. Acqusition of knowledge in the control of a simulated technical system. Le Travail humain. 1997; 60 61-85
- 36 DeKeyser V, Woods D D. Fixation errors: failures to revise situation assessment in dynamic and risky systems. Colombo AG, Bustamante AS, eds In Systems Reliability Assessment, Kluwer Academic, Dordrecht, Germany 1990: 231
-
37 DeKeyser V, Woods D D, Masson M, Van Deele A.
Fixation errors in dynamic and complex systems: descriptive forms, psychological mechanisms, potential countermeasures. Technical Report for NATO Division of Scientific Affairs. Brussels, Belgium; Ref Type: Report 1988 - 38 Gaba D M, Fish K J, Howard S K. Zwischenfälle in der Anästhesie. Prävention und Management. Gustav Fischer 1998
- 39 Gaba D M. Human error in anesthetic mishaps. Int Anesthesiol Clin. 1989; 27 137-147
- 40 Schwid H A, O'Donell D. Anesthesiologists' management of simulated critical incidents. Anesthesiology 1992 76
- 41 Rall M. Eisberg der Narkosezwischenfälle. 1997. Ref Type: Personal Communication 1997
- 42 Dörner D. Die Logik des Mißlingens. Rowohlt, Reinbek 1993
- 43 Rall M, Guggenberger H, Gaba D M. Allgemeines Management von Zwischenfällen - Praxis der Patientensicherheit in Anästhesie, Intensiv- und Notfallmedizin. Anasthesiol Intensivmed. Notfallmed Schmerzther, Manuskript eingereicht 2001
- 44 Holzman R S, Cooper J B, Gaba D M, Philip J H, Small S D, Feinstein D. Anesthesia crisis resource management: real-life simulation training in operating room crises. J Clin Anesth. 1995; 7 675-687
- 45 Howard S K, Gaba D M, Fish K J, Yang G, Sarnquist F H. Anesthesia crisis resource management training: teaching anesthesiologists to handle critical incidents. Aviat Space Environ Med. 1992; 63 763-770
- 46 Helmreich R L. On error management: lessons from aviation. BMJ,. 2000; 320 781-785
- 47 Barach P, Small S D. Reporting and preventing medical mishaps: lessons from non-medical near miss reporting systems. BMJ,. 2000; 320 759-763
- 48 Hansis M L, Hansis D E. Der ärztliche Behandlungsfehler. ecomed, Landsberg 1999
- 49 Cohen M R. Why error reporting systems should be voluntary [editorial]. BMJ. 2000; 320 728-729
- 50 Sexton J B, Thomas E J, Helmreich R L. Error, stress, and teamwork in medicine and aviation: cross sectional surveys. BMJ. 2000; 320 745-749
- 51 Leape L L, Woods D D, Hatlie M J, Kizer K W, Schroeder S A, Lundberg G D. Promoting patient safety by preventing medical error. JAMA JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION. 1998; 280 1444-1447
- 52 Berwick D M, Leape L L. Reducing errors in medicine - It's time to take this more seriously. BRITISH MEDICAL JOURNAL. 1999; 319 136-137
- 53 Leape L L, Berwick D M. Safe health care: are we up to it? [editorial]. BMJ. 2000; 320 725-726
- 54 Rall M. Why do we always have to wait for deaths?. http://www. bmj. com/cgi/eletters/320/7235/598/a 2000
- 55 Rall M. It's time to tackle errors in medicine. http://www. bmj. com/cgi/eletters/320/7235/597 2000
Dr. Marcus Rall
Klinik für Anaesthesiologie
Tübinger Patientensicherheits- und
Stimulationszentrum
Universitätsklinikum Tübingen
Hoppe-Seyler-Straße 3
72076 Tübingen
Email: marcus.rall@med.uni-tuebingen.de