AMClogo_China

第二届妇产科安全和质量大会
The 2nd Patient Safety and Quality Improvement Congress of Obstetrics and Gynecology (2nd PSQIC)

很荣幸代表AMC China，受邀到第二届妇产科安全和质量大会发表原位模拟与医疗质量管理的心得。我们试着把灾害管理和风险管理的体系，应用在医疗疏失管理上。利用原位模拟（in-situ)，串连医疗风险管理常用的RCA和FMEA两种工具，让原本比较静态，被动的模式，能够更动态、迭代，建立成循环。透过临床真实环境与团队的模拟，找到容易被视为理所当然的潜在威胁因子，找出解决之道，再透过原位模拟来验证（validate)改进措施的可行性。
当然，风险不是只有「负面的威胁」，「正面的机会」，在PMI的定义中，也被纳入风险的定义中。在原位模拟中，不会只有看到疏失，也会看到好的，值得肯定的部分。何不用来鼓励人员？作为最佳实践？或者用来提高评量基准呢？
用前瞻、积极的观念来看待风险，降低疏失因子，掌握优势，并以系统性的观念来加强医疗服务的质量用管理。
To err is human, to learn is human, to improve is human.

On behalf of AMC China, it is my honor to be invited to give presentation on in-situ simulation and hospital service quality management in the 2nd Patient Safety and Quality Improvement Congress of Obstetrics and Gynecology (PSQIC), Shanghai.
In my presentation, I try to rethink medical error management using the mature system cycle of disaster and risk management. By using in-situ simulation to connect RCA and FEMA, the most 2 common tools in medical error management, we are able to connect the 2 tools and make static medical error analysis mode more dynamic and iterative, and thus build a cycle of medical error management. In-situ simulation helps us to find potential negative risks that are often neglected, then again, we can find solutions and use in-situ simulation to validate feasibility of solutions proposed.
Another important part in my presentation is, by Project Management Institute (PMI) definition on risk, “risk” is not just negative threat, but also positive opportunity. In in-situ simulation, we see both negative factors and also positive ones. We can use positive factors to encourage hospital staffs, make it best practice or improve evaluation benchmarks. We encourage our healthcare partners to see “risk” in a prospective and active way, to lower negative factors and increase strength, to improve patient safety and medical service quality management.