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英格兰国家健康体系(NHS)最近发布了一系列推荐,旨在保证接受侵入性操作患者的医疗更安全1。这些推荐部分基于对未遂事件、严重事故和所谓“绝不该发生的事件”进行的国家和地方性分析得出的教训,展现为一种总体性文件框架。NHS鼓励下属机构组织与医院员工及患者携手,共同开发及维护他们自己的标准化操作规范,并开发出评估这些操作规范是否被遵从的方法。这些标准充实了旨在改善患者安全性干预措施的庞大“武器库”。这个进
The National Health System (NHS) in England recently released a series of recommendations designed to make the health care of patients undergoing invasive procedures more secure1. These recommendations are based in part on the lessons learned from national and local analyzes of attempted, serious and so-called “events that should never happen” as a general framework of documents. NHS encourages affiliate organizations to work with hospital staff and patients to jointly develop and maintain their own standardized practices and to develop ways to evaluate compliance with these practices. These standards complement the vast “arsenal” of interventions designed to improve patient safety. This into