Читать книгу Pathy's Principles and Practice of Geriatric Medicine - Группа авторов - Страница 296

On a more general level, patient safety researchers have used many methods to enhance our knowledge of the causes of adverse events. It is important to appreciate that when an adverse event occurs, we may be quick to judge or to blame the actions or omissions of individuals, but careful inquiry usually shows that deficiencies in our systems are also at fault. We have learnt much from other industries in this respect. Investigation of major disasters such as the Chernobyl nuclear explosion, the Space Shuttle Challenger crash, and the Paddington rail accident identified ‘violations of procedure’ or problems resulting from actions or omissions by people at the scene. However, further analysis of these events revealed ‘latent conditions’²¹ further upstream in the process, which allowed these violations to occur and have such a devastating effect. ‘Latent conditions’ are often a result of gradual and unintentional erosion of safety‐enhancing processes because of other pressures: for example, cutting training budgets to reduce costs. Further in the background are often deeply ingrained cultural and organizational issues, some of which may be elusive and difficult to resolve. Of course, it is very well to learn about the underlying causes of these non‐healthcare‐related disasters, but the question that most clinicians will ask at this stage is how they are relevant to us. Although healthcare is similar to these industries in some respects, such as the high level of inherent risks and the presence of well‐meaning and dedicated staff, it is very different in others, such as diversity, often non‐centralized administration, uncertainty, and unpredictability.