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Risikomanagement und Fehlerkultur

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Die Intensivmedizin
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Zusammenfassung

Fehler sind in der Medizin häufig, und die damit verbundene Morbidität, Letalität und ökonomischen Auswirkungen sind beträchtlich [1, 2]. Die Intensivstation steht als multidisziplinäres, hochkomplexes und stark technisiertes System im Zentrum der stationären Krankenversorgung. Die Häufigkeit eines Fehlers, Zwischenfalls oder unerwünschten Ereignisses ist, neben anderen Faktoren, v. a. von der Intensität der geleisteten Therapie und Pflege, dem Schweregrad der Erkrankung der Patienten und der Komplexität der organisatorischen Abläufe abhängig [3–5].

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Literatur

  1. Bates DW, Spell N, Cullen DJ, Burdick E, Laird N, Petersen LA et al. (1997) The costs of adverse drug events in hospitalized patients. Adverse Drug Events Prevention Study Group. JAMA 277 (4): 307–311

    Article  PubMed  CAS  Google Scholar 

  2. Kohn LT, Corrigan JM, Donaldson MS (1999) To err is human: building a safer health system. National Academy Press, Washington, DC

    Google Scholar 

  3. Weingart SN, Wilson RM, Gibberd RW, Harrison B (2000 ) Epidemiology of medical error. BMJ 320 (7237): 774–777

    Article  PubMed  CAS  Google Scholar 

  4. Wilson RM, Runciman WB, Gibberd RW, Harrison BT, Newby L, Hamilton JD (1995) The quality in Australian Health Care Study. Med J Aust 163 (9): 458–471

    PubMed  CAS  Google Scholar 

  5. Bates DW, Miller EB, Cullen DJ, Burdick L, Williams L, Laird N et al. (1999) Patient risk factors for adverse drug events in hospitalized patients. ADE Prevention Study Group. Arch Intern Med 159 (21): 2553–2560

    Article  PubMed  CAS  Google Scholar 

  6. Reason J (2003) Human error. Cambridge University Press, Cambridge

    Google Scholar 

  7. Flanagan JC (1954) The critical incident technique. Psychol Bull 51:327–359

    Article  PubMed  CAS  Google Scholar 

  8. Leape LL (1994) Error in medicine. JAMA 272 (23): 1851–1857

    Article  PubMed  CAS  Google Scholar 

  9. Beckmann U, Bohringer C, Carless R, Gillies DM, Runciman WB, Wu AW et al. (2003) Quality improvement in intensive care – evaluation of two methods: »facilitated« incident monitoring and retrospective medical chart review. Crit Care Med 31: 1006–1011

    Article  PubMed  Google Scholar 

  10. Barach P, Small SD (2000) Reporting and preventing medical mishaps: lessons from non-medical near miss reporting systems. BMJ 320: 759–763

    Article  PubMed  CAS  Google Scholar 

  11. Chang A, Schyve PM, Croteau RJ, O´Leary DS, Loeb JM (2005) The JCAHO patient safety event taxonomy: a standardized terminology and classification schema for near misses and adverse events. Int J Qual Health Care 17: 95–105

    Article  PubMed  Google Scholar 

  12. Reason J (2000) Human error: models and management. BMJ 320: 768–770

    Article  PubMed  CAS  Google Scholar 

  13. Osmon S, Harris CB, Dunagan C, Prentice D, Fraser VJ, Kollef MH (2004) Reporting of medical errors: An intensive care unit experience. Crit Care Med 32 (3): 727–732

    Article  PubMed  Google Scholar 

  14. Walsh T, Beatty PCW (2002) Human factors error and patient monitoring. Physiol Meas 23: R111–R132

    Article  PubMed  CAS  Google Scholar 

  15. Alvarez GA, Cavanagh P (2004) The capacity of visual short-term memory is set by visual information load and by number of objects. Psychol Sci 15: 106–111

    Article  PubMed  CAS  Google Scholar 

  16. Reason J (1990) The contribution of latent human failures to the breakdown of complex systems. Philos Trans R Soc Lond Ser B Biol Sci 327: 475–484

    Article  CAS  Google Scholar 

  17. Valentin A, Capuzzo M, Guidet B, Moreno RP, Dolanski L, Bauer P et al. (2006) Patient safety in intensive care: results from the multinational Sentinel Events Evaluation study. Intensive Care Med 32: 1592–1598

    Article  Google Scholar 

  18. Donchin Y, Gopher D, Olin M, Badihi Y, Biesky M, Sprung CL et al. (1995) A look into the nature and causes of human errors in the intensive care unit. Crit Care Med 23 (2): 294–300

    Article  PubMed  CAS  Google Scholar 

  19. Sexton JB, Thomas EJ, Helmreich RL (2000) Error, stress and teamwork in medicine and aviation: cross-sectional surveys. BMJ 320: 745–749

    Article  PubMed  CAS  Google Scholar 

  20. Vincent C, Stanhope N, Crowley-Murphy M (1999) Reasons for not reporting adverse incidents. J Eval Clin Pract 5: 13–21

    Article  PubMed  CAS  Google Scholar 

  21. Leape LL, Brennan TA, Laird N, Lawthers AG, Localio AR, Barnes BA et al. (1991) The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study II. N Engl J Med 324 (6): 377–384

    Article  PubMed  CAS  Google Scholar 

  22. Berwick DM, Leape LL (1999) Reducing errors in medicine. Qual Health Care 8 (3): 145–146

    Article  PubMed  CAS  Google Scholar 

  23. Eisen LA, Savel RH (2009) What went right: lessons for the intensivist from the crew of US Airways Flight 1549. Chest 136 (3): 910–917

    Article  PubMed  Google Scholar 

  24. Valentin A, Capuzzo M, Guidet B, Moreno R, Metnitz B, Bauer P et al. (2009) Errors in administration of parenteral drugs in intensive care units: multinational prospective study. Br Med J 338: b814

    Article  Google Scholar 

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Frutiger, A., Graf, J. (2011). Risikomanagement und Fehlerkultur. In: Burchardi, H., Larsen, R., Marx, G., Muhl, E., Schölmerich, J. (eds) Die Intensivmedizin. Springer, Berlin, Heidelberg. https://doi.org/10.1007/978-3-642-16929-8_8

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  • DOI: https://doi.org/10.1007/978-3-642-16929-8_8

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