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{安全管理小故事——一位护士发错药之后}
玛丽在纽约一家医院已经工作了三年。一天给病人发药时,她张冠李戴发错了药,幸好被及时发现,没有酿成事故。但医院的管理部门依然对这件事情展开了严厉地“问责”。
首先问责护理部。他们从电脑中调出最近一段时间病历记录,发现“玛丽负责区域病人增加了30%,而护士人手并没有增加”。调查部门认为护理部没有适时增加人手,造成玛丽工作量加大,劳累过度。人员调配失误。
然后问责人力资源部门的心理咨询机构。玛丽的家里最近有什么问题?询问得知,她的孩子刚两岁,上幼儿园不适应,整夜哭闹,影响到玛丽晚上休息。调查人员询问后认为“医院的心理专家没有对她进行帮助,失职!”
最后问责制药厂。专家认为“谁也不想发错药,这里可能有药物本身的原因”。他们把玛丽发错的药放在一起进行对比,发现几种常用药的外观、颜色相似,容易混淆。他们向药厂发函:建议改变常用药片外包装,或改变药的形状,尽可能减少护士对药物的误识。
那几天玛丽特别紧张,不知医院如何处理。医院心理专家走访了她,告诉她不用担心病人赔偿事宜,已由保险公司解决。还与玛丽夫妻探讨如何照顾孩子,并向社区申请给予她10小时义工帮助。玛丽下夜班,义工照顾孩子,以保证她能充分休息。同时医院特别批准她“放几天假,帮助女儿适应幼儿园生活”。
这以后,玛丽工作更加认真细致,也没有人发生类似错误。她和同事们都很喜欢自己的工作,想一直做下去。
任何事故的发生都不是简单的认为是员工直接引起的,根据屏障分析法,必然是穿过层层屏障才会发生事故,因此,发生事故后,应至少从管理层、组织层、制度层和个人层四个层面进行彻底的原因分析,以找出根本原因,彻底杜绝事件重发。
自由空间 2012-3-21 21:13:00 | 阅读全文 | 回复(15) | 引用通告 | 编辑
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员工的心理介入应该怎么做呢,王老师有没有这方面的经验?因为根据观察,有许多员工出现不安全行为,正是因为心理情绪的问题,特别是夜班人员。