Gesundheitsökonomie & Qualitätsmanagement 2007; 12(3): 185-188
DOI: 10.1055/s-2006-927114
Originalarbeit

© Georg Thieme Verlag KG Stuttgart · New York

Maßnahmen zur Fehlervermeidung am Beispiel einer Schraubenosteosynthese

Mistake Proofing in Open Reduction and Internal Fixation with ScrewsM. F. Fischmeister1
  • 1Unfallkrankenhaus der Allgemeinen Unfallversicherungsanstalt Linz
Further Information

Publication History

Publication Date:
11 June 2007 (online)

Zusammenfassung

Es werden die wichtigsten Maßnahmen zur Fehlervermeidung beschrieben und dabei die Failure Modes and Effects Analysis (FMEA) an einem Beispiel der Schraubenosteosysnthese dargestellt. Die Berechnung des Complexity Factor und seine Anwendung zur Fehlerverringerung wird dargelegt. Poka Yokei und die Anwendung von „Simple Rules” zur Beeinflussung von Situationen dynamischer Komplexität werden beschrieben.

Abstract

The most important organizational strategies for mistake proofing are described and a failure modes and effects analysis on the example of a screw-osteosynthesis is shown. Complexity factors are computed and their use in order to decrease failure rates is demonstrated. The use of Poka Yokei and “simple rules” in situations of dynamic complexity are described.

Literatur

  • 1 Reason J. Human error, models and management.  BMJ. 2000;  320 768-770
  • 2 Barach P, Small S D. Reporting and preventing medical mishaps: lessons from non-medical near miss reporting systems.  BMJ. 2000;  320 759-763
  • 3 Failure modes and effects analysis (FMEA).  Institute for Healthcare Improvement. 2003;  , www.ihi.org
  • 4 Using Health Care Failure Mode and Effect Analysis™.  , http://www.va.gov/NCPS/SafetyTopics/HFMEA/HFMEA_JQI.pdf
  • 5 Leonard M, Frankel A, Simmonds T. et al .Achieving Safe and Reliable Healthcare: Strategies and Solutions. ACHE Management Series Chicago; Health Administration Press 2004
  • 6 Hinckley C M. Make no mistake, an outcome-based approach to mistake-proofing. Portland Oregon; Productivity Press 2001
  • 7 Grout J. Mistakes and Complexity in Health Care (White Paper).  , http://www.mistakeproofing.com/medical/White_Paper/white_paper.html
  • 8 Hirano H. 5 s for operators. Portland Oregon; Productivity Press 1996
  • 9 Plsek P E, Greenhalgh T. The challenge of complexity in healthcare.  BMJ. 2001;  323 625-628
  • 10 Plsek P E, Wilson T. Complexity, leadership, and management in healthcare organisations.  BMJ. 2001;  323 746-749
  • 11 Bonnabry P, Cingria C, Sadeghipour F. et al . Use of a systematic risk analysis method to improve safety in the production of paediatric parenteral nutrition solutions.  Qual Saf Health Care. 2005;  14 93-98
  • 12 Westrum R. A typology of organisational cultures.  Qual Saf Health Care. 2004;  13 22-27
  • 13 Amalberti R, Auroy Y, Berwick D. et al . Five System Barriers to achieving ultrasafe health care.  Ann Intern Med. 2005;  142 756-764

Dr. Martin Franz Fischmeister

Ferihumerstraße 11

4040 Linz/Urfahr; Austria

Email: martin@fischmeister.info

URL: http://www.fischmeister.info

    >