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A Journal on Orthopedics and Traumatology

Official Journal of the Piedmontese-Ligurian-Lombard Society of Orthopedics and Traumatology
Indexed/Abtracted in: EMBASE, Scopus, Emerging Sources Citation Index

Ferquency: Quarterly

ISSN 0026-4911

Online ISSN 1827-1707


Minerva Ortopedica e Traumatologica 2006 October;57(5):405-11


Clinical Risk Management and adverse events

Raciti I. M. 1, Mosso R. 1, Azzolina M. C. 2, Arione R. 2, Davini O. 3, Rapellino M. O. 1

1 Struttura Complessa Qualità e Risk Management Ospedaliero, ASO S. Giovanni Battista, Torino
2 Direzione Sanitaria P.O. Molinette, ASO S. Giovanni Battista, Torino
3 Direttore Sanitario ASO S. Giovanni Battista, Torino

Clinical Risk Management is responsible to identifying, to prevent and to manage the mistake risk in the sanitary world, with the purpose to improve the quality of the sanitary performances and to ensure the patients safe. The mistake or adverse event is the failure of a planned action (execution mistake) or the use of uncorrected planning to reach an aim (planning mistake). The mistakes are to be different from the malpractice, because while the first are considers accompleshed in good faith or as accidents, the malpractice is the consequence of a guilty negligence, imperizia and imprudence of the operator who can have heavy penal and/or civil consequences. The development of Risk Management support a cultural approach which, does not stretch to the individual guilt, but the search of the determinant factors inside the organization. Reason has introduced the model of the Swiss - cheese in which the obvious error is caused by succession of actions that, in some ways, exceed the various mechanisms of control, defensive layers. In medicine the categories most frequent of mistake are: diagnostic mistakes (wrong diagnoses done after a clinical exame or the execution of procedures with the support of technologies), medication mistakes (made in prescribe, dispense and give out a medicament), therapeutic mistakes (made during the therapy) prevention mistakes (for example: wrong or absent communication).

language: Italian


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