由器官誤植談病人的安全

Organ Transplantation Error and Patient Safety

高照村(Jau-Tsuen Kao)

《Journal of Biomedical & Laboratory Sciences》 24卷1期 (2011/03) Pp. 1-4

https://doi.org/10.30046/JBLS.201103.0006

摘要

在健康照護過程中因為制度的不健全或人為的疏失而造成病人的不良後果時有所聞，造成的傷害輕者可以忽視，但嚴重的則會導致病人的死亡，因此病人安全也就成為大家所重視的目標。但一件意外的發生往往是由許多種失誤累積而成，平時這些小的偏差並未造成不良後果，也就習以為常，但當這些小偏差同時發生時，則將釀成重大的危險意外，瑞士乳酪模式正可用來說明失誤的案例，所謂冰凍三尺非一日之寒，想避免意外的發生得靠平常的努力，建立起好的制度，時時監測，時時改善。

關鍵字

病人安全 ； 器官移植 ； 瑞士乳酪模式

並列摘要

Defective system or human error in health care organizations often causes medical errors. While the minor damage is negligible, fatality of patient will be caused by a severe mistake. The patient safety has recently received a great deal of attention. Every accident is accumulated from a lot of small errors. People are used to these small errors, because it does no harm. However, when these small mistakes take place together, a disaster happens. The Swiss cheese model explains system accidents. To provide a safe patient care, health care organization needs to establish an intact system and operate the procedure strictly and monitor frequently.

並列關鍵字

Patient safety ； Organ transplantation ； the Swiss cheese model of system accidents