Lernen aus Fehlern im Krankenhaus

Abstract

Analysis of incidents and near-incidents is an important factor for continuous improvement in patient safety in hospitals and for the promotion of organizational learning. From a system perspective, accidents occur when decision-making at several levels of a working system is faulty and the safety barriers fail. Human error is inevitable but accidents are not. Errors can be used as an opportunity for organizational learning and this is especially true for incidents when patients come to no harm. Starting with explanations of a system perspective on errors, this paper deals with the prerequisites for organizational learning and general rules for establishing incident reporting systems in hospitals.

Piloting and evaluating feasibility of a training program to improve patient safety for inter-professional inpatient care teams – study protocol of a cluster randomized controlled trial

“…By improving communication within the team of healthcare professionals and with patients, such programs can also contribute to improvements in healthcare delivery and make healthcare safer [17, 24–31]. Furthermore, discussions and reflections of adverse events, errors and their consequences for patients can build the foundation for open communication and thus a practiced safety culture [32]. With regard to patient involvement, patients have been found to possess the willingness, ability and desire to play an active role in error prevention in accordance with their capabilities [28, 33–36].…”