國外航空風險管理方法及績效的循證評價--醫療風險系列研究之一_《中國循證醫學雜志》

作者：

謝瑜 ¹ , 文進 ¹ , 高曉鳳 ¹ , 孫丁 ¹ , 李幼平 ¹ , 梁瀟瀟 ¹ , 詹小青 ¹ , 楊天桂 ² , 王羽 ³ , 張宗久 ³ , 趙明綱 ³ , 陸君 ⁴ , 柳琪林 ⁴

1. 四川大學華西醫院循證醫學與臨床流行病學中心, 成都 610041　2. 四川大學華西醫院醫院質量管理處, 成都 610041　3. 中國衛生部醫政司, 北京 1000444. 中國醫師協會, 北京 100711;

關鍵詞：

航空風險醫療風險風險管理循證評價

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目的　循證評價國外航空風險管理的經驗及其對醫療行業的借鑒意義.　
方法　計算機檢索SCO-PUS(1969～2006)等相關數據庫及網站,輔以手工檢索,全面收集有關航空風險及其管理的歷史沿革、經驗、模型及航空風險與醫療風險關系的文獻.
結果　與醫療同為高技術,高風險,高專業性行業的航空業現已形成從信息收集到分析、處理的一整套風險管理體系,在實踐中形成了獨具特色的信息報告系統、提供了各種切實可行的風險分析工具和模型,尤其強調系統層面建設.
結論　我國醫療行業可以結合自身特點:①借鑒航空業的成功經驗,建立針對事件和小差錯的報告系統,但必須構建與其相適宜的管理機制和法律環境,并可選擇高風險科室與部門進行試點.②借鑒航空業團隊資源管理(CRM)的教程和模式,注重非技術技能的訓l練.③針對人為因素的作用,加強醫護人員外部環境的建設.④建立風險數據庫,科學總結和分析,更好地使用前瞻性風險分析工具.⑤各醫療單位可以先借鑒航空業成熟的安全文化評估工具進行自評,找出差距后學習航空業構建安全文化的種種措施.

引用本文： 謝瑜,文進,高曉鳳,孫丁,李幼平,梁瀟瀟,詹小青,楊天桂,王羽,張宗久,趙明綱,陸君,柳琪林. 國外航空風險管理方法及績效的循證評價--醫療風險系列研究之一. 中國循證醫學雜志, 2006, 06(2): 131-138. doi: 復制

1.	http://www.boeing.com/news/techissues/pdf/statsum.pdf.
2.	Institute of Medicine,To err is human:building a safer health system Washington DC:National Academy Press; 2000.
3.	Reason J.Human error:model and management.BMJ,2000;320:768-770.
4.	ICAO,Annex 13.International Standards and Recommended Practices for Aircraft Accident and Incident Investigation.8th Edition,July 1994.
5.	Janic.M.An assessment of risk and safety in civil aviation.Journal of Air Transport Management,2005; 6 (1):43-50.
6.	Normra K.Managing risks in airline industry.Japan and the WorldEconomy,2003; 15:469-479.
7.	Barach P,Small SD.Reporting and preventing medical mishaps:les sons from non-medical near miss reporting systems.BM J,2000;320:759-763.
8.	ODEGARD S.Safety management in civil aviation a useful method for improved safety in medical care? Safety Science Monitor,2000; 4(1):1-12.
9.	US Federal Aviation Authority,US FAR 91.25.Aviation Safety Reporting Program:Prohibition against use of reports for enforcement purposes; 1985.
10.	McIntyre GR.The application of system safety engineering and management techniques at the US Federal Aviation Administration (FAA) Safety Science,2002; 40 (1-4):325-335.
11.	Stoop JA.Accident investigations:Trends,paradoxes and opportuni ties.International Journal of Emergency Management,2003; 1 (2):170-182.
12.	Johnson CW.How will we get the data and what will we do with it then? Issues in the reporting of adverse healthcare events,Qual.Saf.Health Care,2003; 12; 64-67.
13.	Staender S.Incident reporting systems in medicine.Zeitschrifi furArztliche Fortbildung und Qualitatssicherung,2001; 95 (7):479-484.
14.	Stoop JA.Independent accident investigation:A modem safety tool.Journal of Hazardous Materials,2004; 111 (1-3):39-44.
15.	Lu AYL.Analysis of aviation occurrence using aviation safety community risk management model approach.Transactions of the Aeronautical and Astronautical Society of the Republic of China,2004; 36 (4):375 -382.
16.	Majumda A,Ochieng WY,Nalder P.Trend analysis of controllercaused airspace incidents in New Zealand,1994-2002.Transportation Research Record,2004; (1888):22 -33.
17.	Guohua L.Sunsan P,Yandong Q.Driving-while-intoxicated history as a risk marker for general aviation pilots.Accident Analysis and Prevention,2005; 37 (1):179-184.
18.	McFadden KL.Risk models for analyzing pilot-error at US airlines:A comparative safety study.Computers and Industrial Engineering,2003; 44(4):581 -593.
19.	Allen HW,Abate ML Work process analysis:a necessary step in the development of decision support systems.An aviation safety case study.Interacting with Computers,1999; 11 (6):623-643.
20.	Edkins GD.The INDICATE safety program:Evaluation of a meth od to proactively improve airline safety performance.Safety Science,1998; 30(3) 275-295.
21.	McFadden KL.Predicting pilot-error incidents of US airline pilots using logistic regression.Applied Ergonomics,1997; 28 (3):209 212.
22.	Wreathall J,Nemeth C.Assessing risk:the role of probabilistic riskassessment(PRA) in patient safety improvement.Qual.Saf.Health Care,2004; 13:206-212.
23.	Barnett A.Air safety:End of the golden age? Journal of the Opera tional Research Society,2001; 52(8):849 -854.
24.	Sachon M,Pate-Cornell E.Delays and safety in airline maintenance.Reliability Engineering and System Safety,2000; 67 (3):301-309.
25.	Hunter DR.Measurement of hazardous attitudes among pilots.International Journal of Aviation Psychology,2005; 15 (1):23-43.
26.	Conway GA,Mode NA,Berman MD.Flight safety in Alaska:Comparing attitudes and practices of high-and low-risk air carriers.Aviation Space and Environmental Medicine,2005; 76 (1):52-57.
27.	Thomson ME..Aviation risk perception:A comparison between experts and novices.Risk Analysis,2004; 24 (6):1585-1595.
28.	Thomas MJW.Predictors of threat and error management:Identification of core nontechnical skills and implications for training systems design.International Journal of Aviation Psychology,2004; 14 (2):207-231.
29.	Li G,Baker SP,Oing Y.Age,flight experience,and risk of crash involvement in a cohort of professional pilots.American Journal of Epidemiology,2003; 157 (10):874-880.
30.	Sicard B,Taillemite JP,Jouve E.Risk propensity in commercial and military pilots.Aviation Space and Environmental Medicine,2003; 74(8):879 -881.
31.	Goode JH.Are pilots at risk of accidents due to fatigue? Journal of Safety Research,2003 ;34 (3):309-313.
32.	Wenner CA,Drury CG.Analyzing human error in aircraft ground damage incidents.International Journal of Industrial Ergonomics,2000; 26 (2):177 -199.
33.	Daniel J.Crew resource management training-clinicians’ reactions and attitudes.AORN Journal,2005; 82(2):213-226.
34.	Latorella KA,Prabhu PV.A review of human error in aviation maintenance and inspection.International Journal of Industrial Ergonomics,2000; 26:133-161.
35.	Besco R O.Human performance breakdowns are rarely accidents:they are usually very poor choices with disastrous results.Journal of Hazardous Materials,2004; 115:155-161.
36.	Krulak DC.Human Factors in Maintenance:Impact on Aircraft Mis hap Frequency and Severity.Aviation Space and Environmental Medicine,2004; 75 (5):429-432.
37.	Bove T,AndersEn HB.The effect of an advisory system on pilots’go/no-go decision during take-off.Reliability Engineering and System Safety,2002; 75(2):179 -191.
38.	Wiegmann DA,Zhang H,Vonthaden TL.Safety culture:An integrative review.International Journal of Aviation Psychology,2004; 14(2):117 -134.
39.	Hudson P.Applying the lessons of high risk industries to health care.Qual.Saf.Health Care,2003;12:7 -12.
40.	Geller ES,Hickman JS,Pettinger CB.The Airline Lifesaver:A 17years analysis of a technique to prompt the delivery of a safety message.Journal of Safety Research,2004; 35:357-366.
41.	Wang Y.Establishing medical risk monitoring and early warning system for quality improvement and patient safety.Chinese Journal of Evidence-Bused Medicine,2006; 6 (1):1-2.王羽.建立醫療風險監測預警體系,提高醫療質量,保障病人安全中國循證醫學雜志,2006;6(1):1～2.
42.	Cohen MR.Why error reporting systems should be voluntary.BMJ,2000; 320:728-729.
43.	Leape LL.Reporting of Adverse Events.N Engl Med,347 (20):1633-1638.
44.	Marx DA,Slonim AD.Assessing patient safety risk before the injury occurs:an introduction of sociotechnical probabilistic risk modeling in health care Qual.Saf.Health Care,2003; 12:33 -38.
45.	Leonard M,Graham S,Bonacum D.The human factor:the critical importance of effective teamwork and communication in providing safe care.Qual.Saf.Health Care,2004; 13:85 -90.
46.	Thomas EJ,Sherwood GD,Helmreich RL.Lessons from aviation:teamwork to improve patient safety.Nursing Economics,2003; 21 (5):241 -244.
47.	Pape TM.Applying airline safety practices to medication administration.Medsurg Nursing,2003; 12(2):77-95.

1. http://www.boeing.com/news/techissues/pdf/statsum.pdf.
2. Institute of Medicine,To err is human:building a safer health system Washington DC:National Academy Press; 2000.
3. Reason J.Human error:model and management.BMJ,2000;320:768-770.
4. ICAO,Annex 13.International Standards and Recommended Practices for Aircraft Accident and Incident Investigation.8th Edition,July 1994.
5. Janic.M.An assessment of risk and safety in civil aviation.Journal of Air Transport Management,2005; 6 (1):43-50.
6. Normra K.Managing risks in airline industry.Japan and the WorldEconomy,2003; 15:469-479.
7. Barach P,Small SD.Reporting and preventing medical mishaps:les sons from non-medical near miss reporting systems.BM J,2000;320:759-763.
8. ODEGARD S.Safety management in civil aviation a useful method for improved safety in medical care? Safety Science Monitor,2000; 4(1):1-12.
9. US Federal Aviation Authority,US FAR 91.25.Aviation Safety Reporting Program:Prohibition against use of reports for enforcement purposes; 1985.
10. McIntyre GR.The application of system safety engineering and management techniques at the US Federal Aviation Administration (FAA) Safety Science,2002; 40 (1-4):325-335.
11. Stoop JA.Accident investigations:Trends,paradoxes and opportuni ties.International Journal of Emergency Management,2003; 1 (2):170-182.
12. Johnson CW.How will we get the data and what will we do with it then? Issues in the reporting of adverse healthcare events,Qual.Saf.Health Care,2003; 12; 64-67.
13. Staender S.Incident reporting systems in medicine.Zeitschrifi furArztliche Fortbildung und Qualitatssicherung,2001; 95 (7):479-484.
14. Stoop JA.Independent accident investigation:A modem safety tool.Journal of Hazardous Materials,2004; 111 (1-3):39-44.
15. Lu AYL.Analysis of aviation occurrence using aviation safety community risk management model approach.Transactions of the Aeronautical and Astronautical Society of the Republic of China,2004; 36 (4):375 -382.
16. Majumda A,Ochieng WY,Nalder P.Trend analysis of controllercaused airspace incidents in New Zealand,1994-2002.Transportation Research Record,2004; (1888):22 -33.
17. Guohua L.Sunsan P,Yandong Q.Driving-while-intoxicated history as a risk marker for general aviation pilots.Accident Analysis and Prevention,2005; 37 (1):179-184.
18. McFadden KL.Risk models for analyzing pilot-error at US airlines:A comparative safety study.Computers and Industrial Engineering,2003; 44(4):581 -593.
19. Allen HW,Abate ML Work process analysis:a necessary step in the development of decision support systems.An aviation safety case study.Interacting with Computers,1999; 11 (6):623-643.
20. Edkins GD.The INDICATE safety program:Evaluation of a meth od to proactively improve airline safety performance.Safety Science,1998; 30(3) 275-295.
21. McFadden KL.Predicting pilot-error incidents of US airline pilots using logistic regression.Applied Ergonomics,1997; 28 (3):209 212.
22. Wreathall J,Nemeth C.Assessing risk:the role of probabilistic riskassessment(PRA) in patient safety improvement.Qual.Saf.Health Care,2004; 13:206-212.
23. Barnett A.Air safety:End of the golden age? Journal of the Opera tional Research Society,2001; 52(8):849 -854.
24. Sachon M,Pate-Cornell E.Delays and safety in airline maintenance.Reliability Engineering and System Safety,2000; 67 (3):301-309.
25. Hunter DR.Measurement of hazardous attitudes among pilots.International Journal of Aviation Psychology,2005; 15 (1):23-43.
26. Conway GA,Mode NA,Berman MD.Flight safety in Alaska:Comparing attitudes and practices of high-and low-risk air carriers.Aviation Space and Environmental Medicine,2005; 76 (1):52-57.
27. Thomson ME..Aviation risk perception:A comparison between experts and novices.Risk Analysis,2004; 24 (6):1585-1595.
28. Thomas MJW.Predictors of threat and error management:Identification of core nontechnical skills and implications for training systems design.International Journal of Aviation Psychology,2004; 14 (2):207-231.
29. Li G,Baker SP,Oing Y.Age,flight experience,and risk of crash involvement in a cohort of professional pilots.American Journal of Epidemiology,2003; 157 (10):874-880.
30. Sicard B,Taillemite JP,Jouve E.Risk propensity in commercial and military pilots.Aviation Space and Environmental Medicine,2003; 74(8):879 -881.
31. Goode JH.Are pilots at risk of accidents due to fatigue? Journal of Safety Research,2003 ;34 (3):309-313.
32. Wenner CA,Drury CG.Analyzing human error in aircraft ground damage incidents.International Journal of Industrial Ergonomics,2000; 26 (2):177 -199.
33. Daniel J.Crew resource management training-clinicians’ reactions and attitudes.AORN Journal,2005; 82(2):213-226.
34. Latorella KA,Prabhu PV.A review of human error in aviation maintenance and inspection.International Journal of Industrial Ergonomics,2000; 26:133-161.
35. Besco R O.Human performance breakdowns are rarely accidents:they are usually very poor choices with disastrous results.Journal of Hazardous Materials,2004; 115:155-161.
36. Krulak DC.Human Factors in Maintenance:Impact on Aircraft Mis hap Frequency and Severity.Aviation Space and Environmental Medicine,2004; 75 (5):429-432.
37. Bove T,AndersEn HB.The effect of an advisory system on pilots’go/no-go decision during take-off.Reliability Engineering and System Safety,2002; 75(2):179 -191.
38. Wiegmann DA,Zhang H,Vonthaden TL.Safety culture:An integrative review.International Journal of Aviation Psychology,2004; 14(2):117 -134.
39. Hudson P.Applying the lessons of high risk industries to health care.Qual.Saf.Health Care,2003;12:7 -12.
40. Geller ES,Hickman JS,Pettinger CB.The Airline Lifesaver:A 17years analysis of a technique to prompt the delivery of a safety message.Journal of Safety Research,2004; 35:357-366.
41. Wang Y.Establishing medical risk monitoring and early warning system for quality improvement and patient safety.Chinese Journal of Evidence-Bused Medicine,2006; 6 (1):1-2.王羽.建立醫療風險監測預警體系,提高醫療質量,保障病人安全中國循證醫學雜志,2006;6(1):1～2.
42. Cohen MR.Why error reporting systems should be voluntary.BMJ,2000; 320:728-729.
43. Leape LL.Reporting of Adverse Events.N Engl Med,347 (20):1633-1638.
44. Marx DA,Slonim AD.Assessing patient safety risk before the injury occurs:an introduction of sociotechnical probabilistic risk modeling in health care Qual.Saf.Health Care,2003; 12:33 -38.
45. Leonard M,Graham S,Bonacum D.The human factor:the critical importance of effective teamwork and communication in providing safe care.Qual.Saf.Health Care,2004; 13:85 -90.
46. Thomas EJ,Sherwood GD,Helmreich RL.Lessons from aviation:teamwork to improve patient safety.Nursing Economics,2003; 21 (5):241 -244.
47. Pape TM.Applying airline safety practices to medication administration.Medsurg Nursing,2003; 12(2):77-95.

《中國循證醫學雜志》

國外航空風險管理方法及績效的循證評價--醫療風險系列研究之一

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《中國循證醫學雜志》

國外航空風險管理方法及績效的循證評價--醫療風險系列研究之一

摘要 全文 圖表 視頻 參考文獻 施引文獻 補充材料

Format

Content

摘要全文圖表視頻參考文獻施引文獻補充材料