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医疗系统事故分析：STAMP-HFACS方法与灰色关联度的联合应用
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Abstract:
随着我国医疗安全形势的大幅改善，重大医疗安全事故虽有所减少但形势依旧严峻。因此，研究人因因素在医疗事故中的作用对于预防事故具有重要意义。本文基于STAMP-HFACS方法对医疗系统事故的成因进行深入研究。首先介绍STAMP、HFACS的基本概念及其在事故分析中的特点。其次结合这两种方法提出STAMP-HFACS方法，即将HFACS结构的层级整合到STAMP安全控制结构的组件中，说明具体分析步骤并用于分析典型医疗事故。此外，采用HFACS结合灰色关联分析方法对医疗事故人因错误进行因素统计，包括HFACS四层级的四个指标以及其13个类别分别进行关联性分析，阐述各因素与医疗事故发生的关联程度以及深入分析医疗事故人因错误与各因素之间的关联性。结论指出医疗系统事故是多层级因素相互作用的结果，明确组织影响中管理层的失误即组织流程对事故发生的重要影响。该方法不仅能够详细深入地阐述该事故发生机理，还为预防和控制医疗事故提供了有效工具。
With the substantial improvement of China’s medical security situation, although major medical safety accidents have decreased, the situation is still grim. Therefore, it is of great significance to study the role of human factors in medical accidents for the prevention of accidents. Based on the STAMP-HFACS method, this paper makes an in-depth study on the causes of medical system accidents. Firstly, the basic concepts of STAMP and HFACS and their characteristics in accident analysis are introduced. Secondly, combining these two methods, the STAMP-HFACS method is proposed, which integrates the hierarchy of the HFACS structure into the components of the STAMP safety control structure, and explains the specific analysis steps and is used to analyze typical medical accidents. In addition, HFACS combined with grey correlation analysis method was used to analyze the factors of human error in medical accidents, including four indexes of HFACS four levels and 13 categories. The correlation between human error in medical accidents and various factors was analyzed in depth, and the correlation between human error in medical accidents and the occurrence of medical accidents was expounded. The conclusion points out that the medical system accident is the result of the interaction of multi-level factors, and clarifies the important influence of management errors in organizational influence, that is, organizational process, on the occurrence of accidents. This method can not only elaborate the mechanism of the accident in detail, but also provide an effective tool for the prevention and control of medical accidents.
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