sechenovSechenov Medical JournalСеченовский вестник2218-73322658-3348Сеченовский Университет10.47093/2218-7332_2018.3.17-24sechenov-67Research ArticleКЛИНИЧЕСКАЯ МЕДИЦИНАModern principles of management of patient safety (systematic review)Современные принципы управления безопасностью пациентов (систематический обзор)ВосканянЮ. Э.VoskanyanY. E.voskanyanue_mmch@mail.ruФГБОУ ДПО «Российская медицинская академия непрерывного профессионального образования» Минздрава РоссииРоссияRussian Medical Academy of Continuous Professional EducationRussian Federation201830092018031724Copyright © Voskanyan Y.E., 20182018Восканян Ю.Э.Voskanyan Y.E.Данная работа распространяется под лицензией Creative Commons Attribution 4.0.This work is licensed under a Creative Commons Attribution 4.0 License.https://www.sechenovmedj.com/jour/article/view/67

The article analyzes the research works devoted to the study of principles of management of patient safety. Used medical databases MEDLINE, Cochrane Collaboration, EMBASE, SCOPE, ISI Web of Science for the period 1991-2017. In most studies a strict sequence of origin of the harm associated with healthcare management (adverse event or unintended injury), which is based on constant system of causes - latent threats, is shown. The development of an adverse event begins with the activation of the latent threat and turning it into an active threat of group 1 (dangerous situation), which is the cause of the active threats of group 2 (errors and failures). Active threats of group 2 lead to dangerous events (incidents), which are a potential or real cause of unintended injury. Latent and active threats exist on three levels - personnel, environment and patient. Management of latent threats at all levels is at the heart of patient safety, reducing the frequency and severity of unintended injury.

В статье проведен анализ исследований, посвященных изучению принципов управления безопасностью пациентов. Использованы медицинские базы данных MEDLINE, Cochrane Collaboration, EMBASE, SCOPE, ISI Web of Science за период 1991-2017 гг. В большинстве работ показана строгая последовательность происхождения вреда, свяанного с оказанием медицинской помощи (непреднамеренной травмы или неблагоприятного события), в основе которого лежат постоянные системные причины - латентные угрозы. Развитие неблагоприятного события начинается с активации латентной угрозы и превращения ее в активную угрозу группы 1 (опасную ситуацию), которая является причиной возникновения активных угроз группы 2 (ошибок и сбоев). Активные угрозы группы 2 приводят к возникновению опасных событий (инцидентов), являющихся потенциальной или реальной причиной непреднамеренной травмы. Латентные и активные угрозы существуют на уровнях персонала, среды и пациента. Управление латентными угрозами на всех уровнях лежит в основе обеспечения безопасности пациентов, снижения частоты и тяжести непреднамеренной травмы.

медицинская помощьбезопасность пациентанеблагоприятные событияинцидентактивные угрозылатентные угрозымедицинские ошибкиmedical carepatient safetyadverse eventincidentactual threats (actual failures)latent threats (latent failures)medical errorsReferencesO'Hagan J, Mac Kinnon N.J, Persaud D, Etchegary H. Self-Reported medical errors in seven countries: implications for Canada. Healthcare Quarterly 2009; 12 (Sp.): 55-61.O'Hagan J, Mac Kinnon N.J, Persaud D, Etchegary H. Self-Reported medical errors in seven countries: implications for Canada. Healthcare Quarterly 2009; 12 (Sp.): 55-61.Brennan T.A, Leap L.L, Larid N.M et al. Incidence of adverse events and negligence in hospitalized patients: results of the Harvard Medical Practice Study I. N Engl J Med 1991; 324: 370-6.Brennan T.A, Leap L.L, Larid N.M et al. Incidence of adverse events and negligence in hospitalized patients: results of the Harvard Medical Practice Study I. N Engl J Med 1991; 324: 370-6.Deilkås E.T, Bukholm G, Lindstrøm J.C, Haugen M. Monitoring adverse events in Norwegian hospitals from 2010 to 2013. BMJ Open 2015; 5: 1-6.Deilkås E.T, Bukholm G, Lindstrøm J.C, Haugen M. Monitoring adverse events in Norwegian hospitals from 2010 to 2013. BMJ Open 2015; 5: 1-6.Zegers M, Bruijne M.C, Wagner C et al. Adverse events and potentially preventable deaths in Dutch hospitals: results of a retrospective patient record review study. Qual Saf Health Care 2009; 18: 297-302.Zegers M, Bruijne M.C, Wagner C et al. Adverse events and potentially preventable deaths in Dutch hospitals: results of a retrospective patient record review study. Qual Saf Health Care 2009; 18: 297-302.Makary M.A, Daniel M. Medical error - the third leading cause of death in the US. BMJ 2016; 353 (3): 1-5.Makary M.A, Daniel M. Medical error - the third leading cause of death in the US. BMJ 2016; 353 (3): 1-5.Leap L. Error in Medicine. JAMA 1994; 272 (23): 1851-7.Leap L. Error in Medicine. JAMA 1994; 272 (23): 1851-7.Beuzekom M, Boer F, Akerboom S, Hudson P. Patient safety: latent risk factors. Br J Anaesthes 2010; 105 (1): 52-9.Beuzekom M, Boer F, Akerboom S, Hudson P. Patient safety: latent risk factors. Br J Anaesthes 2010; 105 (1): 52-9.Lawton R, Carruthers S, Gardner P et al. Identifying the latent failures underpinning medication administration errors: an exploratory study. Health Services Res 2012; 47 (4): 1437-59.Lawton R, Carruthers S, Gardner P et al. Identifying the latent failures underpinning medication administration errors: an exploratory study. Health Services Res 2012; 47 (4): 1437-59.El Bardissi A, Wiegmann D, Dearan J et al. Application of the human factors analysis and classification system methodology to the cardiovascular surgery operating room. Ann Thorac Surg 2007; 83: 1412-9.El Bardissi A, Wiegmann D, Dearan J et al. Application of the human factors analysis and classification system methodology to the cardiovascular surgery operating room. Ann Thorac Surg 2007; 83: 1412-9.Reason J. Human error: models and management. Br Med J 2000; 320: 768-70.Reason J. Human error: models and management. Br Med J 2000; 320: 768-70.Hoffmann B, Rohe J. Patient safety and error management. Dtsch Arztebl Int 2010; 107 (6): 92-9.Hoffmann B, Rohe J. Patient safety and error management. Dtsch Arztebl Int 2010; 107 (6): 92-9.Mitchell R, Williamson A, Molesworth B, Chung A. A review of the use of human factors classification frameworks that identify causal factors for adverse events in the hospital setting. Ergonomics 2014; 57 (10): 1443-72.Mitchell R, Williamson A, Molesworth B, Chung A. A review of the use of human factors classification frameworks that identify causal factors for adverse events in the hospital setting. Ergonomics 2014; 57 (10): 1443-72.Carayon P, Schoofs Hundt A, Karsh B et al. Work system design for patient safety: the SEIPS model. Qual Saf Health Care 2006; 15 (Suppl. I): i50-i58.Carayon P, Schoofs Hundt A, Karsh B et al. Work system design for patient safety: the SEIPS model. Qual Saf Health Care 2006; 15 (Suppl. I): i50-i58.Wadhera R, Parker S, Burkhart H et al. Is the “sterile cockpit” concept applicable to cardiovascular surgery critical intervals or critical events? The impact of protocol - driven communication during cardiopulmonary bypass. J Thorac Cardiovasc Surg 2010; 139 (2): 312-9.Wadhera R, Parker S, Burkhart H et al. Is the “sterile cockpit” concept applicable to cardiovascular surgery critical intervals or critical events? The impact of protocol - driven communication during cardiopulmonary bypass. J Thorac Cardiovasc Surg 2010; 139 (2): 312-9.Clancy C, Tornberg D. Team STEPPS: Assuring optimal team - work in clinical settings. Am J Med Qual 2007; 22 (3): 214-7.Clancy C, Tornberg D. Team STEPPS: Assuring optimal team - work in clinical settings. Am J Med Qual 2007; 22 (3): 214-7.Carthey J, de Leval M, Reason J. The human factor in cardiac surgery: errors and near misses in a high technology medical domain. Ann Thorac Surg 2001; 72: 300-5.Carthey J, de Leval M, Reason J. The human factor in cardiac surgery: errors and near misses in a high technology medical domain. Ann Thorac Surg 2001; 72: 300-5.Edmondson A. Learning from failure in health care: frequent opportunities, pervasive barriers. Qual Saf Health Care 2004; 13 (Suppl. II): ii3-ii9.Edmondson A. Learning from failure in health care: frequent opportunities, pervasive barriers. Qual Saf Health Care 2004; 13 (Suppl. II): ii3-ii9.Freed D, Drain J, Kitcat J et al. Death in low - risk cardiac surgery: the failure to achieve a satisfactory cardiac outcome (FI- ASCO) study. Interact Cardiovasc Thorac Surg 2009; 9: 623-5.Freed D, Drain J, Kitcat J et al. Death in low - risk cardiac surgery: the failure to achieve a satisfactory cardiac outcome (FI- ASCO) study. Interact Cardiovasc Thorac Surg 2009; 9: 623-5.Farid S, Page A, Jenkins D et al. FIASCO II failure to achieve a satisfactory cardiac outcome study: the elimination of system errors. Interact Cardiovasc Thorac Surg 2013; 17: 116-9.Farid S, Page A, Jenkins D et al. FIASCO II failure to achieve a satisfactory cardiac outcome study: the elimination of system errors. Interact Cardiovasc Thorac Surg 2013; 17: 116-9.Lyons M. Should patients have a role in patient safety? A safety engineering view. Qual Saf Health Care 2007; 16 (2): 140-2.Lyons M. Should patients have a role in patient safety? A safety engineering view. Qual Saf Health Care 2007; 16 (2): 140-2.Verstappen W, Gaal S, Esmail A, Wensing M. Patient safety improvement programmes for primary care. Review of a Delphi procedure and pilot studies by the LINNEAUS collaboration on patient safety in primary care. Eur J Gen Pract 2015; 21 (Suppl. 1): 50-5.Verstappen W, Gaal S, Esmail A, Wensing M. Patient safety improvement programmes for primary care. Review of a Delphi procedure and pilot studies by the LINNEAUS collaboration on patient safety in primary care. Eur J Gen Pract 2015; 21 (Suppl. 1): 50-5.Molloy G.J, O'Boyle C.A. The SHEL model: a useful tool for analyzing and teaching the contribution of Human Factors to medical error. Acad Med 2005; 80 (2): 152-5.Molloy G.J, O'Boyle C.A. The SHEL model: a useful tool for analyzing and teaching the contribution of Human Factors to medical error. Acad Med 2005; 80 (2): 152-5.Takayanagi K, Hagihara Y. Revised sunflower-SHELL model - an analysis tool to ensure adverse - events' factor analysis and followed by patient safety strategy. Jpn Hosp 2007; 25: 11-8.Takayanagi K, Hagihara Y. Revised sunflower-SHELL model - an analysis tool to ensure adverse - events' factor analysis and followed by patient safety strategy. Jpn Hosp 2007; 25: 11-8.Marsteller J, Wen M, Hsu Y et al. Safety culture in cardiac surgical teams: data from five programs and national surgical comparison. Ann Thorac Surg 2015; 100: 2182-9.Marsteller J, Wen M, Hsu Y et al. Safety culture in cardiac surgical teams: data from five programs and national surgical comparison. Ann Thorac Surg 2015; 100: 2182-9.Sanchez J, Ferdinand F, Fann J. Patient safety science in cardiothoracic surgery: an overview. Ann Thorac Surg 2016; 101: 426-33.Sanchez J, Ferdinand F, Fann J. Patient safety science in cardiothoracic surgery: an overview. Ann Thorac Surg 2016; 101: 426-33.Pronovost P, Weast B, Holzmueller C et al. Evaluation of the culture of safety: survey of clinicians and managers in an academic medical center. Qual Saf Health Care 2003; 12: 405-10.Pronovost P, Weast B, Holzmueller C et al. Evaluation of the culture of safety: survey of clinicians and managers in an academic medical center. Qual Saf Health Care 2003; 12: 405-10.Lilford R, Mohammed M, Braunholtz D, Hofer T. The measurement of active errors: methodological issues. Qual Saf Health Care 2003; 12 (Suppl. II): ii8-ii12.Lilford R, Mohammed M, Braunholtz D, Hofer T. The measurement of active errors: methodological issues. Qual Saf Health Care 2003; 12 (Suppl. II): ii8-ii12.Hibbert P, Williams H. The use of a global trigger tool to inform quality and safety in Australian general practice: a pilot study. Aust Fam Physician 2014; 43 (10): 723-6.Hibbert P, Williams H. The use of a global trigger tool to inform quality and safety in Australian general practice: a pilot study. Aust Fam Physician 2014; 43 (10): 723-6.Michel Ph, Quenon J, de Sarasqueta A, Scemama O. Comparison of three methods for estimating rates of adverse events and rates of preventable adverse events in acute care hospitals. BMJ 2004; 328 (24): 199-202.Michel Ph, Quenon J, de Sarasqueta A, Scemama O. Comparison of three methods for estimating rates of adverse events and rates of preventable adverse events in acute care hospitals. BMJ 2004; 328 (24): 199-202.Pietra L, Calligaris L, Molendini L et al. Medical errors and clinical risk management: state of the art. Act Otorhinolaryng Ital 2005; 25: 339-46.Pietra L, Calligaris L, Molendini L et al. Medical errors and clinical risk management: state of the art. Act Otorhinolaryng Ital 2005; 25: 339-46.Shaw R, Drever F, Hughes H et al. Adverse events and nearmiss reporting in the NHS. Qual Saf Health Care 2005; 14: 279-83.Shaw R, Drever F, Hughes H et al. Adverse events and nearmiss reporting in the NHS. Qual Saf Health Care 2005; 14: 279-83.

The authors declare that there are no conflicts of interest present.