Zusammenfassung
Ein Patient erhält im Rahmen einer größeren abdominalchirurgischen Operation präoperativ einen thorakalen Periduralkatheter. Dieser wird vor der Narkoseausleitung mit einem Lokalanästhetikum bestückt und im Aufwachraum an eine Schmerzpumpe (PCEA) angeschlossen. Nach einem unauffälligen Verlauf im Aufwachraum wird der Patient wach und kreislaufstabil auf die Normalstation zurückverlegt. Gegen 2 Uhr morgens wird der anästhesiologische Dienstarzt von der Nachtschwester darüber informiert, »dass der Periduralkatheter nicht sitzt oder etwas mit der Schmerzpumpe nicht stimmt«. Bei genauerem Nachfragen stellt sich heraus, dass der Patient in den Nachtstunden zunehmend über Schmerzen geklagt habe und eine wiederholte Bolusgabe keine Besserung gebracht hätte.
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Literatur
AHRQ (2008) Becoming a high reliability organization: Operational advice for hospital leaders. AHRQ Publication No. 08-0022, Agency for Healthcare Research and Quality
Argyris C, Schön DA (1999) Die Lernende Organisation. Grundlagen, Methode, Praxis. Klett-Cotta, Stuttgart
Bagnara S, Parlangeli O, Tartaglia R (2010) Are hospitals becoming high reliability organizations? Appl Ergon. 41(5) 713–8
Baitsch C (1993) Was bewegt Organisationen? Selbstorganisation aus psychologischer Perspektive. Campus, Frankfurt a.M., New York
Bali R, Dwivedi A (2006) Healthcare knowledge management. Issues, advances and successes. Springer, Berlin Heidelberg New York
Barrett J, Gifford C et al. (2001) Enhancing patient safety through teamwork training. J Healthc Risk Manag 21:57–65
Bateson G (1972) Steps towards an ecology of mind. Chandler, New York
Bedeian AG (1984) Organizations. Theories and analysis. Saunders College Publishing, New York
Bellabarba J (1997) Zum Konzept der Unternehmenskultur in Krankenhäusern. In Hoefert HW (Hrsg.) Führung und Management im Krankenhaus. Verlag für Angewandte Psychologie, Göttingen, S 99–108
Bellabarba J, Schnappauf D (1996) (Hrsg.) Organisationsentwicklung im Krankenhaus. Verlag für Angewandte Psychologie Göttingen
Billings C, Cook RI, Woods DD, Miller C (1998) Incident Reporting Systems in medicine and experience with the Aviation Safety Reporting System. National Patient Safety Foundation at the AMA, Chicago, Illinois, pp 52–61
Blum LL (1971) Equipment design and «human« limitations. Anesthesiology 35:101–102
Chopra V, Bovill JG (1997) Verbesserung der Sicherheit in der Anästhesie. In: Taylor TH, Major E (Hrsg.) Risiken und Komplikationen in der Anästhesie. Gustav Fischer, Lübeck, S 14–26
CIRS (1998) The Anaesthesia Critical Incident Reporting System on the Internet. [WWW document]. URL: http://www.medana.unibas.ch/cirs/intreng.htm
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
Comelli H (1985) Training als Beitrag zur Organisationsentwicklung. Hanser, München
Conell L (1996) Pilot and controller issues. In: Kanki B, Prinzo VO (eds) Methods and metrics of voice communication. DOT/FAA/AM-96/10. FAA Civil Aeromedical Institute, Oklahoma City
Cooper JB, Cullen DJ, Eichhorn JH, Philip JH, Holzman RS (1993) Administrative Guidelines for Response to an Adverse Anesthesia Event. J Clin Anesth 5: 79–84
Cooper JB, Newbower RS, Long CD, McPeek B (1978) Preventable anesthesia mishaps: a study of human factors. Anesthesiology 49:399–406
Davenport TH, Glaser J (2002) Just-in-time-delivery comes to knowledge management. Harv Bus Rev 80:107–112
Degani A, Wiener EL (1993) Cockpit checklists: Concepts, design, and use. Hum Fact 35:345–59
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
Diekmann P, Reddersen S, Zieger J, Rall M (2008) Video-assisted debriefing in simulation-based training of crisis resource management. In: Kyle R, Murray B (eds.) Clinical simulation. 667–676
Dismukes RK, Gaba DM, Howard SK (2006) So many roads: facilitated debriefing in healthcare. Simul Healthcare 1:1–3
Edwards JS, Hall MJ, Shaw D (2005) Proposing a systems vision of knowledge management in emergency care. J Operat Res Soc 56:180–192
Eichhorn S (1995) Qualitätsmanagement. In: Eichhorn S, Schmidt–Rettig B (Hrsg.) Krankenhausmanagement im Werte- und Strukturwandel. Handlungsempfehlungen für die Praxis. Kohlhammer, Stuttgart, S 321–350
Firth-Cozens J (2001) Teams, culture and managing risk. In: Vincent C (ed) Clinical risk management. Enhancing patient safety. Br Med J Books, London
Flanagan B (2008) Debriefing: Theory and techniques. In: Riley RH (ed.) Manual of simulation in healthcare. Oxford Iniversity Press, Oxford, 155–170
Flanagan JC (1954) The critical incident technique. Psychol Bull 51:327–358
Fletcher GC, McGeorge P, Flin R, Glavin R, Maran N (2002) The role of non-technical skills in anaesthesia: a review of current literature. Br J Anaesth 88:418–429
Flin R, Maran N (2004) Identifying and training non-technical skills for teams in acute medicine. Qual Saf Health Care 13 (Suppl):i80-i84
Frankel AS, Leonard MW, Denham CR (2006) Fair and just culture, team behavior, and leadership engagement: the tools to achieve high reliability. Health Serv Res 41:1690–1709
Gandhi ., 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
Gravenstein N, Kirby RR (1999) Komplikationen in der Anästhesie. Urban & Fischer, Lübeck
Grube C, Graf BM (2003) Risikovermeidung – Simulatoren in der Anästhesie. In: List WF, Osswald PM, Hornke I (Hrsg.) Komplikationen und Gefahren in der Anästhesie. Springer, Berlin, S 18–25
Hales BM, Pronovost PJ (2006) The checklist – a tool for error management and performance improvement. J Crit Care 21:231–35
Hammond J, Brooks J (2001) Helping the helpers: the role of critical incident stress management, Crit Care 5: 315–317
Harrison KT, Manser T, Howard SK, Gaba DM (2006) Use of cognitive aids in a simulated anesthetic crisis. Anesth Analg 103:551–556
Hart EM, Owen H (2005) Errors and omissions in anesthesia: a pilot study using a pilot’s checklist. Anesth Analg 101:246–250
Harvard Health Online (2000). To Err is Human, But… [WWW–dokument] URL http://www.health.harvard.edu/medline/Women/W0300a.html
Hasibeder WR (2010) Does standardization of critical care work? Curr Opin Crit Care [Epub ahead of print]
Hayashi I, Wakisaka M, Ookata N, Fujiwara M, Odashiro M (2007) Actual conditions of the check system for the anesthesia machine before anesthesia. Do you really check? Masui 56:1182–1185
Helmreich RL (2000) On error management. Lessons learned from aviation. BMJ 320:781–5
Hoff LA, Adamowski K (1998) Creating Excellence in Crisis Care: A guide to effective training and program designs. Jossey–Bass, San Francisco
Hofinger G (2010). Zwischenfallberichtssysteme als Instrument organisationalen Lernens aus Fehlern in Krankenhäusern. Wirtschaftpsychologie 4/2010, 87–96
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
Howard SK, Gaba DM, Fish KJ, Yang G, Sarnquist FH (1992) Anesthesia crisis resource management: teaching anesthesiologists to handle critical incidents. Aviation Space Environmental Medicine, 63: 763–770
HSC (HEALTH AND SAFETY COMMISSION) (1993) Third report: organizing for safety. ACSNI Study Group on Human Factors. HMSO, London
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
INSAG-4 (International Nuclear Safety Advisory Group) (1991) Safety Culture. International Atomic Energy Agency, Vienna
James RK, Gilliland BE (2001) Crisis intervention strategies, 4th edn. Wadsworth/Thomson Learning, Belmont
Klopfenstein CE, Van Gessel E, Forster A (1998) Checking the anaesthetic machine: self-reported assessment in a university hospital. Eur J Anaesthesiol 15:314–319
Kox WJ, Spies C (2003) Check–up Anästhesiologie. Standards Anästhesie – Intensivmedizin – Schmerztherapie – Notfallmedizin, Springer, Berlin
Kumar V, Barcellos W, Mehta MP, Carter JG (1988) An analysis of critical incidents in a teaching department for quality assurance: A survey of mishaps during anaesthesia. Anaesthesia, 43: 879–883
Laboutique X, Benhamou D (1997) Evaluation of a checklist for anesthetic equipment before use. Ann Fr Anesth Reanim 16:19–24
Langford R, Gale TC, Mayor AH (2007) Anesthesia machine checking guidelines: Have we improved our practice? Eur J Anaesthesiol 30:1–5
Leape L (2002) Reporting of adverse events. N Engl J Med, 347 (20), 1633–1638
Lederman LC (1992) Debriefing: toward a systematic assessment of theory and practice. Simul Gaming 23:145–160 Lewin K (1951) Field theory in social science. New York: Harper & Row
March MG, Crowley JJ (1991) An evaluation of anesthesiologists’ present checkout methods and the validity of the FDA checklist. Anesthesiology 75:724–729
McCulloch P, Mishra A, Handa A, Dale T, Hirst G, Catchpole K (2009) The effects of aviation-style non-technical skills training on technical performance and outcome in the operating theatre. Qual Saf Health Care 18(2): 109–115
McDonell LK, Kimberly KJ, Dismukes RK (1997) Facilitating LOS debriefings: a training manual, NASA Technical Memorandum 112192, March 1997
Mearns KJ, Flin R (1999) Assessing the state of organizational safety – culture or climate? Cur Psychol 18: 1, 5–17
Melymuka K (2002) Knowledge management helps cut errors by half. Computerworld 36:44
Morey JC, Simon R, Jay GD, Wears RL, Salisbury M, Dukes KA, Berns SD (2002) Error reduction and performance improvement in the emergency department through formal teamwork training: evaluation results of the MedTeams project. Health Serv Res 37:1553–1581
Mort TC, Donahue SP (2004) Debriefing: The basics. In: Dunn WF (ed.) Simulators in critical care and beyond. Society of critical care. 76–83
Naveh ET, Katz-Navon N, Stem Z (2005) Treatment Errors in Healthcare: A Safety Climate Approach. Management Science 51 (6): 948–60
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
NHS Executive (1996) Promoting clinical effectiveness. A framework for action in and through the NHS. NHS Executive, London
Nonaka I, Takeuchi H (1997) Die Organisation des Wissens. Campus, Frankfurt am Main
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
Parker D, Lawrie M, Hudson P (2006) A framework for understanding the development of organizational safety culture. Saf Sci 44; 551–62
Powell SM (2006) Creating a systems approach to patient safety through better teamwork. Biomed Instrum Technol 40:205–207
Probst GJB, Büchel B (1998) Organisationales Lernen. Gabler, Wiesbaden
Pronovost P, Needham D, Berenholtz S, Sinopoli D, Chu H, Cosgrove S, Sexton B, Hyzy R, Welsh R, Roth G, Bander J, Kepros J, Goeschel C (2006) An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med 2006, 355: 2725–2732
Rall M, Manser T, Guggenberger H, Gaba DM, Unertl K (2001) Patientensicherheit und Fehler in der Medizin. Anästhesiologie Intensivmedizin Notfallmedizin Schmerztherapie 36: 321–330
Reader T, Flin R, Lauche K, Cuthbertson BH (2006) Non-technical skills in the intensive care unit. Br J Anaesth 96:551–559
Reason J (1990) Human error. Cambridge University Press, Cambridge UK
Reason J (1997) Managing the Risks of Organizational Accidents. Ashgate, Aldershot
Reason J (1998) Achieving a safe culture: theory and practice. Work & Stress 12:3; 239–306
Reinwarth R (2003) Standard Operating Procedures als Entscheidungsgrundlage in der Luftfahrt. In: Strohschneider S (Hrsg.) Entscheiden in kritischen Situationen. Verlag für Polizeiwissenschaft, Frankfurt am Main, S 13–23
Resar RK (2006) Making Noncatastrophic Health Care Processes Reliable: Learning to Walk before Running in Creating High-Reliability Organizations Health Serv Res. 41(4):1677–89
Riley RH (ed.) (2008) Manual of simulation in healthcare. Oxford University Press. New York
Robson M (1989) Quality circles: a practical guide. Gower, Aldershot
Rudolf JW, Simon R, Dufresne RL, Raemer D (2006) There’s no such thing as «non-judgemental« debriefing: a theory and method for debriefing with good judgement. Simul Healthcare 1:49–55
Runciman WB, Merry AF (2005) Crises in clinical care: an approach to management. Qual Saf Health Care 14: 156–163
Runciman WB, Sellen A, Webb RA, Williamson JA, Currie M, Morgan C, Russell WJ (1993) The Australian Incident Monitoring Study. Errors, incidents and accidents in anaesthetic practice. Anaesth Intensive Care 21:506–519
Salas E, Almeida SA, Salisbury M, King H, Lazzara EH, Lyons R, Wilson KA, Almeida PA, McQuillan R (2009) What are the critical success factors for team training in health care? Jt Comm J Qual Patient Saf 35(8):398–405
Salas E, DiazGranados D, Klein C, Burke CS, Stagl KC, Goodwin GF, Halpin SM (2008) Does team training improve team performance? A meta analysis. Hum Fact 50:6; 903–33
Sawa T, Ohno–Machado L (2001) Generation of dynamically configured check lists for intra-operative problems using a set of covering algorithms. Proc AMIA Symp. 2001: 593–597
Sax HC, Browne P, Mayeqski RJ, Panzer RJ, Hittner KC, Burke RL, Coletta S (2009) Can aviation-based team training elicit sustainable behavioral change? Arch Surg 144(12): 1133–1137
Schein, E. (2004) Organizational culture and leadership. Third edition. Jossey-Bass, San Francisco
Schön DA (1975) Deutero-learning in organizations: learning for increased effectiveness. Organizational Dyn 4:2–16
Schreyögg G (1999) Organisation: Grundlagen moderner Organisationsgestaltung. Wiesbaden
Senge PM (2001) Die fünfte Disziplin. Klett-Cotta, Stuttgart
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
Staender S (2000) Critical incident reporting. With a view on approaches in Anaesthesiology. In: Vincent C, de Mol B (eds) Safety in medicine. Pergamon Elsevier Science, Amsterdam New York, pp 65–82
Stefanelli M (2004) Knowledge and process management in health care organizations. Methods Inf Med 43:525–535
Steinwachs B (1992) How to facilitate a debriefing. Simul Gaming 23:186–195
Taylor- Adams S, Vincent C (2004) Systems Analysis of Clinical Incidents: The London Protocol. Clinical Safety Research Unit, University College, London. Available at: http://www.csru.org.uk
Thomas EJ, Sexton JB, Lasky RE, Helmreich RL, Crandell DS, Tyson J (2006) Teamwork and quality during neonatal care in the delivery room. J Perinatol 26:163–169
van Vegten A (2008) van Vegten, A. (2008). »Incident-Reporting-Systeme als Möglichkeit zum Organisationalem Lernen (nicht nur) aus Fehlern und kritischen Ereignissen. Chancen, Barrieren und Gestaltungsansätze für Berichts-und Lernsysteme im Krankenhaus«. Dissertation an der ETH Zürich. Online verfügbar unter: http://kobra.bibliothek.uni-kassel.de/handle/urn:nbn:de:hebis:34-2009032426765 [Zugriff 27.10.2010].
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
Webb RK, Currie M, Morgan CA, Williamson JA, Mackay P, Russell WJ, Runciman WB (1993) The Australian Incident Monitoring Study: an analysis of 2000 incident reports. Anaesth Intensive Care 21:520–528
Wehner T (1992) Sicherheit als Fehlerfreundlichkeit [Safety as error friendliness]. Westdeutscher Verlag, Opladen
Weick KE (1991) Organizational culture as a source of high reliability. California Management Review 29, 112–27
Weick KE, Sutcliffe KM (2003) Das Unerwartete managen. Wie Unternehmen aus Extremsituationen lernen. Klett-Cotta, Stuttgart
Williamson JA, Webb R, Pryor GL (1985) Anesthesia safety and the ‘critical incident technique’. Aust Clin Rev 6:57–61
Wilson KA, Burke CS, Priest HA, Salas E (2005) Promoting health care safety through training high reliability teams. Qual Saf Health Care 14:303–309
Winters BD, Gurses AP, Lehmann H, Sexton JB, Rampersad CJ, Pronovost PJ (2009) Clinical review: Checklists – translating evidence into practice. Critical Care 13:210 (doi:10.1186/cc7792)
World Health Organization (WHO) (2005). WHO Draft Guidelines for adverse event reporting and learning systems. From Information to action. [online document] URL: http://www.who.int/patientsafety/events/05/Reporting_Guidelines.pdf (accessed 10.10.2010).
Yule S, Flin R, Paterson-Brown S, Maran N (2006) Non-technical skills for surgeons in the operating room: a review of the literature. Surgery 139:140–149
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Pierre, M.S., Hofinger, G., Buerschaper, C. (2011). Zuverlässige Akutmedizin. In: Notfallmanagement. Springer, Berlin, Heidelberg. https://doi.org/10.1007/978-3-642-16881-9_15
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