Medical error, incident investigation and the second victim: Doing better but feeling worse?

摘要

In the past decade, hospitals and healthcare workers have become more familiar with medical errors and the harm they can cause. As a result, incident investigation has become a routine part of the hospital's response to an adverse event. In the USA, the Joint Commission's Sentinel event policy and the Veterans Affairs hospitals' adoption of root cause analysis have made root cause analysis standard operating procedure. Armed with the results of these investigations, research and quality improvement efforts are now taking on system improvements required to create a safer healthcare environment.