醫療疏失擴散模型

醫療疏失擴散模型（英語：healthcare error proliferation model，簡稱HEPM）是英國曼徹斯特大學教授詹姆斯·瑞森（James Reason）所發表的瑞士奶酪模型的改編版本，用來說明：1. 現代醫療系統固有的複雜性，以及2. 這些系統裡面人為錯誤的歸因。HEPM解釋疏失發生的原因和會導致的不良後果的事件序列。這個模型強調組織上和外部的文化在識別、預防、緩解、和防禦措施所能發揮的作用。 醫療系統之所以複雜，是因為它們在結構（例如護理單位、藥房、急診室、手術室），還有專業（例如護理人員、醫生、藥劑師、行政管理人員、治療師）之上種類繁多，而關聯的要素之間能夠相互適應，並能從經驗中學習，以及改變。“複雜適應系統”（CAS）這個名詞是由在跨學科的聖菲研究所（SFI）的約翰·霍蘭德和默里·蓋爾曼兩位學者所提出。隨後，露絲·安德森（Ruth A. Anderson）、魯賓·麥克丹尼爾（Rubin McDaniels）、和保羅·西里爾斯（英语：Paul Cilliers）等學者把CAS的理論和研究擴展，納入社會科學（例如教育和醫療衛生）之中運用，。 HEPM把瑞士奶酪模型理論用到具有複雜性質的醫療系統和集成架構之上。瑞士奶酪模型把複雜，而能自我適應的系統與多孔的瑞士奶酪切片相提並論。切好的奶酪片被稱為防禦層，用來表達這些切片在系統中的作用和功能，而這些作用和功能具有攔截和防止危險的能力。這些防禦層代表離散的位置或是組織級別，而這些位置或組織級別可能本身具有錯誤，並讓錯誤發展。保護層的功能包含四種：1）組織領導能力，2）風險監督，3）不安全做法的情況，以及4）不安全執行後的結果。 HEPM把醫院描述為具有多個防禦層，配備有維持關鍵防禦工事所需的基本要素。透過檢查防禦層的屬性，潛在的故障點，可顯示疏失發生的原因。專家們討論在CAS中對這些保護層的重要性作檢查，也把臨床醫生的心理安全列入考慮。這個HEPM把詹姆斯·瑞森的開創性理論更加擴展。 這個模型把CAS當作一種關鍵特性。這種複雜的系統有獨特的自我組織能力，同時透過非線性關係發揮相互作用，其中專業人員充當信息處理者並與環境共同演進。醫療衛生提供者在系統中扮演不同的角色，使用不同的方法來處理信息，以解決組織內和跨組織之間的整體性問題。 CAS是在一個醫療衛生提供機構中，同時有多種臨床和行政代理人做非線性的交互行動，而其中的作業人員和患者是信息處理者，全部會與環境共同演進，達到安全可靠，以患者為中心的結果（英语：patient-centered outcomes）。 不良反應 循證醫學 醫院認證（英语：Hospital accreditation） 醫源病，也可寫為英語：Iatrogenic disorder 國際醫療衛生認證（英语：International healthcare accreditation） 潛在人為錯誤（英语：Latent human error） 醫療疏失 護理學 患者安全組織（英语：Patient safety organization） 彼得·普羅諾沃斯特（英语：Peter Pronovost） 根本原因分析 嚴重不良事件 瑞士奶酪模型 Palmieri, P. A., DeLucia, P. R., Ott, T. 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