瑪麗在紐約一家醫院已經(jīng)工作了三年。一天給病人發(fā)藥時(shí),她張冠李戴發(fā)錯了藥,幸好被及時(shí)發(fā)現,沒(méi)有釀成事故。但醫院的管理部門(mén)依然對這件事情展開(kāi)了嚴厲地“問(wèn)責”。
首先問(wèn)責護理部。他們從電腦中調出最近一段時(shí)間病歷記錄,發(fā)現“瑪麗負責區域病人增加了30%,而護士人手并沒(méi)有增加”。調查部門(mén)認為護理部沒(méi)有適時(shí)增加人手,造成瑪麗工作量加大,勞累過(guò)度。人員調配失誤。
然后問(wèn)責人力資源部門(mén)的心理咨詢(xún)機構,旣惖募依镒罱惺裁磫(wèn)題?詢(xún)問(wèn)得知,她的孩子剛兩歲,上幼兒園不適應,整夜哭鬧,影響到瑪麗晚上休息。調查人員詢(xún)問(wèn)后認為“醫院的心理專(zhuān)家沒(méi)有對她進(jìn)行幫助,失職!”
最后問(wèn)責制藥廠(chǎng)。專(zhuān)家認為“誰(shuí)也不想發(fā)錯藥,這里可能有藥物本身的原因”。他們把瑪麗發(fā)錯的藥放在一起進(jìn)行對比,發(fā)現幾種常用藥的外觀(guān)、顏色相似,容易混淆。他們向藥廠(chǎng)發(fā)函:建議改變常用藥片外包裝,或改變藥的形狀,盡可能減少護士對藥物的誤識。
那幾天瑪麗特別緊張,不知醫院如何處理。醫院心理專(zhuān)家走訪(fǎng)了她,告訴她不用擔心病人賠償事宜,已由保險公司解決。還與瑪麗夫妻探討如何照顧孩子,并向社區申請給予她10小時(shí)義工幫助,旣愊乱拱,義工照顧孩子,以保證她能充分休息。同時(shí)醫院特別批準她“放幾天假,幫助女兒適應幼兒園生活”。
這以后,瑪麗工作更加認真細致,也沒(méi)有人發(fā)生類(lèi)似錯誤。她和同事們都很喜歡自己的工作,想一直做下去。
任何事故的發(fā)生都不是簡(jiǎn)單的認為是員工直接引起的,根據屏障分析法,必然是穿過(guò)層層屏障才會(huì )發(fā)生事故,因此,發(fā)生事故后,應至少從管理層、組織層、制度層和個(gè)人層四個(gè)層面進(jìn)行徹底的原因分析,以找出根本原因,徹底杜絕事件重發(fā)。
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