Classifying and interpreting threats to patient safety in hospitals: insights from aviation
基于航空安全研究，通过对三家医院的访谈，发现医院对患者安全事件的分类受专业视角、责任认知、事件偶发性和监控技术影响，且决策者常将危险事件归入不可报告类别，这挑战了标准化事件定义的有效性。
Abstract We examine how the information gathered about patient safety‐related events is influenced by the interpretation and classification of these events in hospitals and by the context in which hospitals operate. Building on aviation safety studies, we developed research questions to guide a qualitative, interview‐based study of three hospitals. We found that having a specific (or general) definition of an event was important for aviation safety information systems, but was not salient for hospitals. In these hospitals, event classification was influenced by professional perspectives, perceived professional responsibility, event contingencies, and surveillance technology. In both contexts, decision makers avoided reporting potentially dangerous events by classifying them in non‐reportable categories. The importance of industry context for these results underscores the need for industry‐specific midlevel conceptual frameworks. Healthcare policy‐makers advocate standardizing event definitions to promote learning, but if organizational factors influence definitions and classification schemes, this may undermine the usefulness of centralized error reporting. Copyright © 2006 John Wiley & Sons, Ltd.