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Organisation, Fehler und Sicherheit

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Human Factors und Patientensicherheit in der Akutmedizin

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Zusammenfassung

Dieses Kapitel stellt Organisationen als Systeme dar, die jeweils eine spezifische Organisationskultur haben. Sicherheitskultur als die „DNS der Sicherheit“ wird diskutiert, ehe verschiedene wichtige Organisationstheorien vorgestellt werden: der Human-Factors-Ansatz, der die Unvermeidbarkeit von Fehlern in Organisationen betont, Normans Theorie der „normalen“ durch die Gestaltung von Systemen verursachten Unfälle sowie Ansätze zu Hochzuverlässigkeit, aus denen die Medizin Nutzen ziehen kann. Darüber hinaus werden Möglichkeiten und Grenzen des Lernens von der zivilen Aviatik diskutiert. Als Beispiele für Einflussfaktoren, die im Sinne latenter Fehler auf das Handeln der Ärzte und Pflegekräfte „am scharfen Ende“ des Systems wirken, werden Konzepte der Ablauforganisation, Medizingerätetechnik und Personalmanagement dargestellt.

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Literatur

  • Amalberti R, Auroy Y, Berwick D, Barach P (2005) Five system barriers to achieving ultrasafe health care. Ann Intern Med 142(9): 756–764

    Article  PubMed  Google Scholar 

  • Alvesson M (2002) Understanding organizational culture. Sage Publications, London

    Book  Google Scholar 

  • Argyris C (1957) Personality and organization. Harper and Row, New York

    Google Scholar 

  • Argyris C, Schön DA (1996) Organizational learning II: theory, method and practice. Addison–Wesley, Reading, Massachusetts

    Google Scholar 

  • Badura B, Feuerstein G (1996) Systemgestaltung im Gesundheitswesen: Zur Versorgungskrise der hochtechnisierten Medizin und den Möglichkeiten ihrer Bewältigung. Juventa, Weinheim

    Google Scholar 

  • Bedeian AG (1984) Organizations. Theories and analysis. Saunders College Publishing, New York

    Google Scholar 

  • Bell JH, Harrsion DA, Carr B (1995) Resuscitation skills of trainee anaesthetists. Anaesthesia 50: 692–694

    Article  PubMed  CAS  Google Scholar 

  • Black RJ (2003) Organisational culture: creating the influence needed for strategic success. Dissertation.com, London

    Google Scholar 

  • Bolman LG, Deal TE (1984) Modern approaches to understanding and managing organizations. Jossey–Bass, London

    Google Scholar 

  • Burke CS, Salas E, Wilson-Donnelly K, Priest H (2004) How to turn a team of experts into an expert medical team: guidance from the aviation and military communities. Qual Saf Health Care 13 (Suppl 1):i96–i194

    Article  PubMed  PubMed Central  Google Scholar 

  • Carayon P (Hrsg) (2006) Handbook of human factors and ergonomics in health care and patient safety (Human Factors and Ergonomics Series). Erlbaum, Mahwah

    Google Scholar 

  • Chopra V, Bovill JG, Spierdijk J, Koornneef F (1992) Reported significant observations during anaesthesia: a prospective analysis over an 18-month period. Br J Anaesth 68:13–18

    Article  PubMed  CAS  Google Scholar 

  • Cohen M, Kimmel N, Benage M, Hoang C, Burroughs T, Roth C (2004) Implementing a Hospitalwide Patient Safety Program for Cultural Change. Joint Commission Journal on Quality and Safety 30 (8): 424–31

    PubMed  Google Scholar 

  • Cooper JB, Newbower RS, Long CD, McPeek B (1978) Preventable anesthesia mishaps: a study of human factors. Anesthesiology 49:399–406

    Article  PubMed  CAS  Google Scholar 

  • Cooper JB, Newbower RS, Kitz RJ (1984) An analysis of major errors and equipment failures in anesthesia management: considerations for prevention and detection. Anesthesiology 60:34–42

    Article  PubMed  CAS  Google Scholar 

  • Currie M (1989) A prospective survey of anaesthetic critical events in a teaching hospital. Anaesth Intensive Care 17:403–411

    PubMed  CAS  Google Scholar 

  • Denison D (1996) What is the difference between organisational culture and organisational climate? A native’s point of view on a decade of paradigm wars. Academy of Management Review, 21(3), 619–654

    Google Scholar 

  • EN 60601 (2004) Teil 1-6: Medizinische elektrische Geräte - Allgemeine Festlegungen für die Sicherheit - Ergänzungsnorm: Gebrauchstauglichkeit

    Google Scholar 

  • Entin EE, Serfaty D (1999) Adaptive team coordination. Hum Factors 41:312–325

    Article  Google Scholar 

  • Fahlbruch B, Schöbel M, Marold J (2012) Sicherheit. In: Badtke-Schaub P, Hofinger G, Lauche K (Hrsg.) Human Factors. Psychologie sicheren Handelns in Risikobranchen. Springer, Heidelberg, 21–38

    Google Scholar 

  • Flin R, Maran N (2004) Identifying and training non-technical skills for teams in acute medicine. Qual Saf Health Care 13(Suppl):i80–i84

    Article  PubMed  PubMed Central  Google Scholar 

  • Gaba DM (1989) Human error in anesthetic mishaps. Int Anesth Clin 27:137–147

    Article  CAS  Google Scholar 

  • Gaba DM (2011) Have we gone too far in translating ideas from aviation to patient safety? –No-. BMJ 342, 198–9

    Article  Google Scholar 

  • Gandhi TK, Graydon-Baker E, Huber C, Whittemore A, Gustafson M (2005) Closing the Loop: Follow-Up and Feedback in a Patient Safety Program. Joint Commission Journal on Quality and Patient Safety 31 (11): 614–21

    PubMed  Google Scholar 

  • Gouldner AW (1959) Organizational analysis. In: Merton RK, Broom L, Cottrell LS (eds) Sociology today. Basic Books, New York

    Google Scholar 

  • Guldenmund FW (2000) The nature of safety culture: a review of theory and research. Safety Science 34; 215–57

    Article  Google Scholar 

  • Hatfield A, Tronson M (2001) The Complete Recovery Room Book. University Press, Oxford

    Google Scholar 

  • Helmreich RL (1998) The downside of having a brain: reflections on human error and CRM. University of Texas Aerospace Crew Research Project Technical Report 98–04

    Google Scholar 

  • Helmreich RL, Merritt AC, Wilhelm JA (1999) The evolution of crew resource management in commercial aviation. Int J Aviat Psychol 9:19–32

    Article  PubMed  CAS  Google Scholar 

  • Helmreich RL (2000) On error management: Lessons from aviation. BMJ 320, 781–5

    Article  PubMed  CAS  PubMed Central  Google Scholar 

  • Hoff T, Jameson L, Hannan E, Flink E (2004) A review of the literature examining linkages between organizational factors, medical errors, and patient safety. Med Care Res Rev 6:3–37

    Article  Google Scholar 

  • Hoffmann B, Müller V, Rochon J, Gondan M, Müller B, Albay Z, Weppler K, Leifermann M, Mießner C, Güthlin C, Parker D, Hofinger G, Gerlach FM (2013) Patient safety culture in general practice: open randomized controlled trial. BMJ Quality and Safety in Healthcare. bmjqs-2013-001899 Published Online First: 16 August 2013

    Google Scholar 

  • Hofmann DA, Mark B (2006) An Investigation of the Relationship between Safety Climate and Medication Errors as Well as Other Nurse and Patient Outcomes. Personnel Psychology 59 (4): 847–69

    Article  Google Scholar 

  • Hollnagel E, Woods DD, Leveson N (eds) (2006) Resilience engineering. Concepts and precepts. Ashgate, Aldershot

    Google Scholar 

  • HSC (HEALTH AND SAFETY COMMISSION) (1993) Third report: organizing for safety. ACSNI Study Group on Human Factors. HMSO, London

    Google Scholar 

  • INSAG-1 (International Nuclear Safety Advisory Group) (1986) Summary Report on the Post-Accident Review Meeting on the Chernobyl Accident. International Atomic Energy Agency, Vienna

    Google Scholar 

  • INSAG-4 (International Nuclear Safety Advisory Group) (1991) Safety Culture. International Atomic Energy Agency, Vienna

    Google Scholar 

  • Jung H (2001) Personalwirtschaft. Oldenbourg, München

    Google Scholar 

  • Kao LS, Thomas EJ (2008) Navigating towards improved surgical safety using aviation-based strategies. J Surg Res 145; 327–35

    Article  PubMed  Google Scholar 

  • Kieser A, Kubicek H (1992) Organisation. Springer, Berlin

    Google Scholar 

  • Kieser A (2002) Organisationtheorien. Kohlhammer, Stuttgart

    Google Scholar 

  • Kohn L, Corrigan J, Donaldson M (1999) To err is human: Building a Safer Health System. Committee on Quality of Health Care in America, Institute of Medicine (IOM). National Academy Press, Washington DC

    Google Scholar 

  • LaPorte TR (1982) On the design and management of nearly error-free organizational control systems. In: Sills DL, Wolf CP, Shelanski VB (eds) Accident at Three-Mile Island: the human dimensions. Westview, Boulder, Colorado, pp 185–200

    Google Scholar 

  • LaPorte TR, Consolini PM (1991) Working in Practice but not in Theory: Theoretical Challenges of High Reliability organizations. Journal of Public administration Research and Theory, 1, 19–47

    Google Scholar 

  • Levy PD, Dancy JN, Stowell SA, Hoekstra JW, Arthur CL, Wilson CH, Bednar JM, Dorman T, Hiestand B (2014) Lessons in Flying: Crew Resource Management as a Quality Improvement Method for Acute Coronary Syndromes Care. Critical Pathways in Cardiology: A Journal of Evidence-Based Medicine. 13:1; 36–42

    Google Scholar 

  • Lewis GH, Vaithianathan R, Hockey PM, Hirst G, Bagian JP (2011) Counterheroism, common knowledge, and ergonomics: concepts from aviation that could improve patient safety. Milbank Quart 89(1):4–38

    Article  Google Scholar 

  • Malik F (1984) Strategie des Managements komplexer Systeme. Ein Beitrag zur Management–Kybernetik evolutionärer Systeme. Paul Haupt, Bern/Stuttgart

    Google Scholar 

  • Manser T, Wehner T (2003) Wissensorientierte Kooperation in der Medizin – Ein Konzept und seine Implikationen für die Praxis. In: Ulich E (Hrsg.) Arbeitspsychologie in Krankenhaus und Arztpraxis. Huber, Bern, S 323–340

    Google Scholar 

  • Manser T (2012) Komplexität handhaben – Handeln vereinheitlichen – Organisationen sicher gestalten. In Badke-Schaub P, Hofinger G, Lauche K (Hg.) Human Factors. Psychologie sicheren Handelns in Hochrisikobranchen. Springer, Heidelberg u.a., 295–311

    Google Scholar 

  • Mearns KJ, Flin R (1999) Assessing the state of organizational safety – culture or climate? Cur Psychol 18: 1, 5–17

    Article  Google Scholar 

  • Moray N (1994) Error reduction as a systems problem. In: Bogner MS (ed) Human error in medicine. Erlbaum, Hillsdale, 67–91

    Google Scholar 

  • Morell RC, Eichhorn JH (eds) (1997) Patient safety in anesthetic practice. Churchill Livingstone, New York

    Google Scholar 

  • Nance JJ (2008) Why hospitals should fly: the ultimate flight plan to patient safety and quality care. Healthcare Press, Bozeman MT

    Google Scholar 

  • Naveh ET, Katz-Navon N, Stem Z (2005) Treatment Errors in Healthcare: A Safety Climate Approach. Management Science 51 (6): 948–60

    Article  Google Scholar 

  • Neal A, Griffin M (2006) A Study of the Lagged Relationships among Safety Climate, Safety Motivation, Safety Behavior, and Accidents at the Individual and Group Levels. Journal of Applied Psychology 91 (4): 946–53

    Article  PubMed  Google Scholar 

  • Norman DA (1988) The psychology of everyday things. Basic Books, New York

    Google Scholar 

  • O’Connor RE, Slovis CM, Hunt RC, Pirrallo RG, Sayre MR (2002) Eliminating errors in emergency medical services: realities and recommendations. Prehosp Emerg Care 6:107–113

    Article  PubMed  Google Scholar 

  • Ornato JP, Peberdy MA (2014) Applying lessons from commercial aviation safety and operations to resuscitation. Resuscitation 85(2):173–6

    Article  PubMed  Google Scholar 

  • Parker D, Lawrie M, Hudson P (2006) A framework for understanding the development of organizational safety culture. Saf Sci 44; 551–62

    Article  Google Scholar 

  • Pawlowsky P, Mistele P (Hg.) (2008) Hochleistungsmanagement: Leistungspotenziale in Organisationen gezielt fördern. Gabler, München

    Book  Google Scholar 

  • Pearse RM, Moreno RP, Bauer P, Pelosi P, Metnitz P, Spies C, Vallet B, Vincent JL, Hoeft A, Rhodes A (2012) Mortality after surgery in Europe: a 7 day cohort study. Lancet 380: 1059–65

    Article  PubMed  PubMed Central  Google Scholar 

  • Perrow C (1984) Normal accidents: living with high-risk technologies. Basic Books, NewYork

    Google Scholar 

  • Perrow C (1994) Accidents in high-risk systems. Technol Stud 1:1–38

    Google Scholar 

  • Perrow C (1999) Normal Accidents. Living with High–Risk Technologies. Princeton University Press, Princeton

    Google Scholar 

  • Rampersad C, Rampersad SE (2007) Can medicine really learn anything from aviation? Or are patients and their disease process too complex? Sem Anesth 26; 158–66

    Google Scholar 

  • Rasmussen J (1982) Human errors: a taxonomy for describing human malfunction in industrial installations. J Occup Accid 4:311–335

    Article  Google Scholar 

  • Reason J (1990a) Human Error. Cambridge University Press, Cambridge

    Book  Google Scholar 

  • Reason J (1990b) The contribution of latent human failures to the breakdown of complex systems. Phil Trans R Soc Lond 327: 475–84

    Article  CAS  Google Scholar 

  • Reason J (1997) Managing the risks of organizational accident. Ashgate, Aldershot

    Google Scholar 

  • Reason J (1998) Achieving a safe culture: theory and practice. Work & Stress 12:3; 239–306

    Article  Google Scholar 

  • Renz B, Angele MK, Jauch KW, Kasparek MS, Kreis M, Müller MH (2012) Kann die Chirurgie wirklich von der Luftfahrt lernen? Zentralbl Chir 137; 149–154

    Article  PubMed  CAS  Google Scholar 

  • Ricci M, Panos AL, Lincoln J, Salerno TA, Warshauer L (2012) Is aviation a good model to study human errors in health care? Am J Surg 203; 798–801

    Article  PubMed  Google Scholar 

  • Roberts KH (1990) Managing high reliability organizations. Calif Manage Rev 32:101–113

    Google Scholar 

  • Rochlin GI (1993) Defining “high reliability” organizations in practice: a taxonomic prologue. In: Roberts KH (ed) New challenges to understanding organizations. Macmillan, New York, 11–32

    Google Scholar 

  • Rogers J (2011) Have we gone too far in translating ideas from aviation to patient safety? –Yes-. BMJ 342, 198–9

    Article  Google Scholar 

  • Shaw J, Calder K (2008) Aviation is not the only industry: healthcare could look wider for lessons on patient safety. Qual Saf Health Care 17:314

    Article  PubMed  Google Scholar 

  • Schein E (2004) Organizational culture and leadership. Third edition. Jossey-Bass, San Francisco

    Google Scholar 

  • Schmutz J, Manser T (2013) Do team processes really have an effect on clinical performance? A systematic literature review. Br J Anaesth 110 (4):529–44

    Article  PubMed  CAS  Google Scholar 

  • Schreyögg G (2006) Organisation. Grundlagen moderner Organisationsgestaltung. Gabler Verlag

    Google Scholar 

  • Schulman PR (1993) The analysis of high reliability organizations: a comparative framework. In: Roberts KH (ed) New challenges to understanding organizations. Macmillan, New York, 33–54

    Google Scholar 

  • Schwappach D, Conen D (2012) Patientensicherheit – wen kümmert es?, Interdisciplinary Contributions to Hospital Management: Medicine, Patient Safety and Economics. URL: http://www.clinotel-journal.de/article-id-006.html

  • Sablotzki A, Schubert S, Kuhn C, Radke J, Czeslick E (2003) Die Behandlung von Notfällen im Krankenhaus – Probleme und Management. Anaesthesiologie und Reanimation 28: 32–37

    PubMed  CAS  Google Scholar 

  • Senge P (1990) The fifth discipline: The art and practice of the learning organization. Doubleday, New York

    Google Scholar 

  • Schulte-Zurhausen M (2002) Organisation. Vahlen, München

    Google Scholar 

  • Singer S., Gaba D, Falwell A, Lin S, Hayes J, Baker L (2009) Patient Safety Climate in 92 US Hospitals: Differences by Work Area and Discipline. Medical Care 47 (1): 23–31

    Article  PubMed  Google Scholar 

  • Thomas EJ, Helmreich RL (2002) Will airline safety models work in medicine? In: Rosenthal MM, Sutcliffe KM (eds) Medical error: What do we know? What do we do? Jossey–Bass, San Francisco, 217–234

    Google Scholar 

  • Toff NJ (2010) Human factors in anaesthesia: lessons from aviation. BJA 105 (1): 21–5 (2010)

    Article  PubMed  CAS  Google Scholar 

  • Valentin A, Capuzzo M, Guidet B, Moreno RP, Dolanski L, Bauer P, Metnitz PG (2006) Patient safety in intensive care: results from the multinational Sentinel Events Evaluation (SEE) study. Intensive Care Med 32:1591–1598

    Article  PubMed  Google Scholar 

  • Vaughan D (1997) The Challenger launch decision: risky technology, culture, and deviance at NASA. University of Chicago Press, Chicago, Illinois

    Google Scholar 

  • Vicente KJ (2004) The human factor. Revolutionizing the way people live with technology. Routledge, New York

    Google Scholar 

  • Vogus TJ, Sutcliffe KM (2007) The Safety Organizing Scale: Development and Validation of a Behavioral Measure of Safety Culture in Hospital Nursing Units. Medical Care 45 (1): 46–54

    Article  PubMed  Google Scholar 

  • Webb RK, Russell WJ, Klepper I, Runciman WB (1993) The Australian Incident Monitoring Study. Equipment failure: an analysis of 2000 incident reports. Anaesth Intensive Care 21:673–677

    PubMed  CAS  Google Scholar 

  • Webster CS (2002) Why anaesthetising a patient is more prone to failure than flying a plane. Anaesthesia 57(8):819–20

    PubMed  CAS  Google Scholar 

  • Weick KE (1991) Organizational culture as a source of high reliability. California Management Review 29, 112–27

    Article  Google Scholar 

  • Weick K, Roberts KH (1993) Collective Mind in Organizations: Heedful Interrelating on Flight Decks. Administrative Science Quarterly, 38: 357–381

    Article  Google Scholar 

  • Weick K, Sutcliffe R (2003) Das Unerwartete managen. Klett-Cotta, Stutgart

    Google Scholar 

  • Wiedemann R, Badtke-Schaub P (2012) Aktuelle Themen und zukünftige Entwicklungen in der Luftfahrt. In: Badtke-Schaub P, Hofinger G, Lauche K (Hrsg.) Human Factors. Psychologie sicheren Handelns in Risikobranchen. Springer Heidelberg 221–34

    Google Scholar 

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Authors and Affiliations

  1. Klinik für Anästhesiologie, Universitätsklinikum Erlangen, Erlangen, Deutschland

    Dr. med. Michael St.Pierre DEAA

  2. Human Factors Forschung Beratung Training, Team HF PartG, Remseck, Deutschland

    Dr. phil. Gesine Hofinger

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  1. Dr. med. Michael St.Pierre DEAA
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  2. Dr. phil. Gesine Hofinger
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Correspondence to Michael St.Pierre DEAA .

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St.Pierre, M., Hofinger, G. (2014). Organisation, Fehler und Sicherheit. In: Human Factors und Patientensicherheit in der Akutmedizin. Springer, Berlin, Heidelberg. https://doi.org/10.1007/978-3-642-55420-9_14

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