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La scienza della decisione applicata alla medicina: aspetti teorici e applicativi.
... It focuses on the circumstances in which the error or the critical event occurs, and it is seen as resulting from a failure of the system, and from an interaction between human, technological, and organizational elements. This perspective, outlined in recent years, has stimulated a punitive-free investigation, which considers possible interactions between the elements that allow the functioning of the system, the circumstances in which the error occurs, and the possible defects in the mechanisms of defense from the error [12, 15, 26, 27]. The systemic approach is a complex approach to the error because it considers multiple causes. ...
In recent years the issue of patient safety has been the subject of detailed investigations, particularly as a result of the increasing attention from the patients and the public on the problem of medical error. The purpose of this work is firstly to define the classification of medical errors, which are distinguished between two perspectives: those that are personal, and those that are caused by the system. Furthermore we will briefly review some of the main methods used by healthcare organizations to identify and analyze errors. During this discussion it has been determined that, in order to constitute a practical, coordinated and shared action to counteract the error, it is necessary to promote an analysis that considers all elements (human, technological and organizational) that contribute to the occurrence of a critical event. Therefore, it is essential to create a culture of constructive confrontation that encourages an open and non-punitive debate about the causes that led to error. In conclusion we have thus underlined that in health it is essential to affirm a system discussion that considers the error as a learning source, and as a result of the interaction between the individual and the organization. In this way, one should encourage a non-guilt bearing discussion on evident errors and on those which are not immediately identifiable, in order to create the conditions that recognize and corrects the error even before it produces negative consequences.
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