You are on page 1of 7

, :

, .

Reason, (1982) "To Err is Human


,
,
. 860 : i F l o r e n c e Nightingale

.
, , ,
; :
... ... :
, , , ,
.
;
.
, ,


, , .

,
. ,
,
, ,

, .
. .
.
17

17

,
,
- -
, , ,
.
:

) (
;
;Latent & Active -
;
;
,
.

,
,
, -
, .

, - ,
, , , ...
2
;Kelly ,1998.Hackel etall ,1996( ) ;(2001),
,
.
:
10

: , -.
.1^, 1^ , , ..

28 2003

EMI


;

, ;

;
;
C
h
e
e
k
,
(1997
.Kelly ,1998
) (
6

10

,

, .
, ,viceo
virtuel , ,
. ,


,
;
;
;
;
, , , ...
). Aiken et all, (1994) , Kozier, (2000) , Mrier et all, (1998
16

11

, ,
, .
,
/ ,
.

,

.
,
, , ,


, ,
,
.
-

,
?


:

,
,
,
,
,

.
). Leape et all, (1991) ; Barnard, (2002) ; Benner, (2002
4

13


.
- ,
.
, .
, ,
,
, .
) ( Sexton etall 2000

, .

, ,
,
,
. ,
:
, , .

, .
22


;
; ;
, ;

28 2003

. -
,
.

,
.

) .Kohn etall .(,2000
, .
,
,
.
2

,
.
, ,
-
,
.Senders &Moray ,()1991
21


,
,

). Hofmann et all, (1998
-

): Benner et all, (2002) , Mrier, )2000

:
: ,
,
) , (.
: ,
,
), Benner et all, (2002) , Kozier et all, (2000
). Ramosz, (2000
:
,
) - Eskeirs ( 1998 ,
,
/ , ,
.
,
,
.

. )(bias
, 90- . ,
.
,
, ,

, M r i e r
, )).1998(, Hackelet all, ( 1
) ,Hofmann et all (,1998

,
, ,
.
11

16

19

,Active error -
: ,.
- .
: , ,
, ,
,
, ,
, , /
,
/ )) , B e n n e r , 2 0 0 2(,Raines20
, : , ,
, , ,

.

18

) Martin ( 2000 :
: ,,
,
: , , ,,
,
: .
18

28 2003

) Raines (2000
.

.1.

^.ZllTll.

til'ki

: -
.
/ -
,
.

.
.


//
.
, .
,
,
,
,
... .)
,
.(23356
,
,
.
- ,
.
,

,
/ ,
.

,
.
,

. .

. / ,
,
, -
, Murie ,(1998).. ( 1 9 9 6 ) ( 2 0 0 0 ) ; Eskeireis,
16

:as1i__11: . L _ Z _ : 1 : _ Z : _ _::

. .

) ! ^ ( ^ , (2000 -
75% .
,
.
,
,:
, .

,
.
, ,
...
.
. .
.
.
.
/ .

)
, - //
4 .(...
1 9



.

-
,accountability ,
, -
.Mayo , ()1996
15

,
.
Benner ,
()IOM )(2002

.Latent error - ,
, ,
- ,

28 2003

.

, ,
.


. ,
.
, ,
.
, ,

. -
.


.
-
, ,
.

. :

.
,
,


, .

,
.
:
-
: - , , -
, ,
, ,
, ,
...
-

28 2003

:
,
, ,
,
, , ,
, .
:
,
/ / .
:

-

:

: . . .
.

.

.

. -
, ,
.

.
- ,
, , , .
.


.
,
.

.
,
:


4

.

:

.
.
:
, , ,
,
-

.
, ,

, .
-
.
,

,

,
.
-
.
.
,

.
,
.
.

,
,
.

,
.
, ,
,
,
.
.
:
, )
,(2001 ,273 )
( .
, .

28 2003

:
Leape, L.L., Brennan, T.A., Laird, N., Lawthers, A.G., Localio, .13
A.R., Barnes, B.A., Hbert, L., Newhouse, J. P., Weiler, P.C., Hiatt,
H. (1991) The Nature of Adverse Events in Hospitalized Patients:
Result of Harvard Medical Practice Study II. New England
Journal of Medicine, 324, p.p.377-384.
Martin, G. A. (2000) Medication Errors. Maryland nurse. 3(2) .14
p.p. 32-33.
Mayo, K. (1996) "Social Responsibility in Nursing Education". .15
Journal of Holistic Nursing, Vol.l4,No.l, p.p. 24-43.
Mrier, C.E. (2000) "Understanding the nature of errors in nursing: . 16
using a model to analyze critical incident reports of errors, which
had resulted in an adverse or potentially adverse event." Journal
of Advanced Nursing, 32(1) p.p. 202-207.
Nightingale, F. (1860) "Notes on Nursing: What it is and What .17
is not". Commemorative Edition. Philadelphia: Lippincott.
Raines, D. A. (2000) "Making Mistakes - Prevention Is Key to .18
Error-Free Health Care. AWHONN Lifelines 4(1), p.p.35-39.
Ramosz, B. (2000). Educate then Medicate. Minnesota Nursing .19
Accent 72(6) p.p. 1-20.
Reason, J.(1982) Human Error. Cambridge, MA: Cambridge .20
University Press.
Senders, J. W. & Moray, N. P. (1991) Human Error: Cause, .21
Prediction, and Reduction. New Jersey: Lawrence Erblaum.
Sexton, J. B., Thomas, E. J. & Helmreich, R.L. (2000) " Error, .22
Stress, and Teamwork in Medicine and Aviation: Cross Sectional
Surveys". British Medical Journal. 320 (7237), p.p. 745-749.
Weitstein, N.( 1971) "Psychology Construct the Female." In .23
Women in Sexist Society: Studies in Power and Powerlessness.
New York:Basic Books

$MZ

. : .( 2001). , .1
, , - ( 1996). , .2
.1-4 ,4 ,
Aiken, T.D. & Catalano, J. T. (1994). " Legal, Ethical and Political .3
Issues in Nursing". Philadelphia: Davis.
Barnard, A. (2002) "Philosophy of Technology and Nursing". .4
Nursing Philosophy 3(1), p.p.15-23.
Benner, P., Vickie, S., Uris, P., Malloch, K., Schwed, K. & Jamison, .5
D. (2002) "Individual, Practice, and System Causes of Errors in
Nursing" JONA, 32(10), p.p.509-523.
Cheek, J.(1997)" Nurses and the Administration of Medications". .6
Clinical Nursing Research 6(3), p.p. 253-274.
Eskreis, T.R. (1998). "Seven Common Legal Pitfalls in Nursing" .7
American Journal of Nursing, 98(4), p.p. 34-40.
Hackel, R., Butt, L. & Banister, G. (1996) "How Nurses Perceive .8
Medication Error" Nursing Management ,27(1), p.p. 31-34.
Hofman, D.A. & Stetzer, A. (1998) "The Role of Safety Climate .9
And Accident Interpretation: Implication for Learning From
Negative Events" Academy of Management Journal. 41 (6), p.p.
644-657.
Kelly, B.(1998) "Preserving Moral Integrity: a Follow-up Study .10
With New Graduate Nurses." Journal of Advanced Nursing
28(5), p.p. 1134-1142.
Kozier, B., Erb, G., Berman, A.J. & Burke, K. (2000) "Legal .11
Aspects of Nursing" in Fundamentals of Nursing. New Jersey:
Prentice Hall Health.
Kohn, L.T., Corrigan, J.M. & Donaldson, M.S. (2000) "Why Do .12
Errors Happen?" in To Err is Human: Building a Safer Health
System. Committee on Quality of Health Care in America, Institute
of Medicine.

2003 28

You might also like