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Clinical Risk Management in radiology. Part I: general background and types of error and their prevention
- 作者:R. Golfieri (1)
L. Pescarini (2) A. Fileni (3) R. Silverio (4) C. Saccavini (5) D. Visconti (6) G. Morana (7) M. Centonze (8)
- 关键词:Radiology ; Error ; Malpractice ; Clinical Risk Management ; Radiologia ; Errore ; Malpractice ; Gestione del rischio clinico
- 刊名:La radiologia medica
- 出版年:2010
- 出版时间:October 2010
- 年:2010
- 卷:115
- 期:7
- 页码:1121-1146
- 全文大小:395KB
- 参考文献:1. Ministero della Salute (2007) Protocollo Sperimentale di Monitoraggio degli Eventi Sentinella. I Rapporto: periodo Sett 2005鈥揊eb 2007. Ministero della Salute, Roma
2. Thomas EJ, Brennan TA (2000) Incidence and types of preventable adverse events in elderly patients: population based review of medical records. BMJ 18:741鈥?44 CrossRef 3. Thomas EJ, Petersen LA (2003) Measuring errors and adverse events in health care. J Gen Intern Med 18:61鈥?7 CrossRef 4. Thomas EJ, Studdert DM, Burstin HR et al (2000) Incidence and types of adverse events and negligent care in Utah and Colorado. Med Care 38:261鈥?71 CrossRef 5. XII Rapporto Pit salute. Tribunale per i Diritti del Malato (CitadinanzAttiva Onlus)- 2008. 鈥淚 cittadini al primo posto. Per una sanit脿 pi霉 umana ed accessibile鈥? www.cittadinanzattiva.it/files/sanita/rapporti/Rapporto%20Pit%20Salute%202006.pdf 銆?a href="http://www.cittadinanzattiva.it/files/sanita/rapporti/Rapporto%20Pit%20Salute%202006.pdf銆? class="a-plus-plus">http://www.cittadinanzattiva.it/files/sanita/rapporti/Rapporto%20Pit%20Salute%202006.pdf銆?/a> 6. Kohn LT, Corrigan JM, Donaldson MS (1999) To err is human: building a safer health system. Committee on Quality of Health Care in America. IOM (Institute of Medicine) National Academy Press, Washington D.C. 7. Olivetti L, Fileni A, De Stefano F et al (2008) La rilevanza medico-legale dell鈥檈rrore in radiologia. (The legal implications of error in radiology). Radiol Med 113:599鈥?08 CrossRef 8. CINEAS Consorzio Universitario per l鈥橧ngegneria nelle Assicurazioni (2002) Quando l鈥檈rrore entra in ospedale. Risk management: perch茅 sbagliando s鈥檌mpari. Le mappe del rischio, i costi, le soluzioni. INC 鈥?Istituto Nazionale per la Comunicazione 鈥?Roma. http://www.cineas.it/doc2/news/allegati/167-quando-errore-ospedale.pdf. Last access 30.6.2010 9. Bonaldi A, Focarile F, Torreggiani A (1994) Curare la qualit脿 (manuale per valutare e migliorare l鈥檃ssistenza sanitaria). Guerini e Associati, Milano 10. AMAMI (2006) Atti del III Congresso Nazionale AMAMI 24鈥?5 febbraio 2006, Padova 11. Tartaglia R (2007) Risultati dello studio nazionale promosso dell鈥橝genas 鈥?Agenzia nazionale servizi sanitari regionali 鈥?(la promozione dell鈥檌nnovazione e la gestione del rischio). Il Sole 24 ore Sanit脿 Anno X, 26:3鈥? 12. Reason J (1990) Human error. Cambridge University Press, Cambridge 13. Reason J (2000) Human error models and management BMJ 320:768鈥?70 CrossRef 14. Tartaglia R (2008) La catena dell鈥檈rrore (Il 鈥淪wiss Cheese Model鈥?come base teorica per l鈥檃nalisi degli incidenti). Radiol Med 113:S73鈥揝75 15. Nuti S, Tartaglia R, Niccolai F (2007) Rischio clinico e sicurezza del paziente (modelli e soluzioni). Il Mulino, Bologna 16. Fiorani M, Ranzani F (2007) Ospedali e sistemi per la sicurezza del paziente. Moretti e Vitali, Milano 17. Fileni A, Magnavita N, Mammi F et al (2007) Malpractice stress syndrome in radiologists and radiotherapists: perceived causes and consequences. Radiol Med 112:1069鈥?084 CrossRef 18. Fileni A, Magnavita N (2006) Dodici anni di osservazioni sul contenzioso assicurativo radiologico. (A 12 years follow-up study of malpractice claims against radiologists in Italy). Radiol Med 111:1009鈥?022 CrossRef 19. Fitzgerald R (2001) Error in radiology. Clin Radiol 52:938鈥?46 CrossRef 20. Fitzgerald R (2005) Radiological error: analysis, standard setting, targeted instruction and teamworking. Eur Radiol 15:1760鈥?767 CrossRef 21. Pescarini L, Inches I (2006) Systematic approach to human error in radiology. Radiol Med 111:252鈥?67 CrossRef 22. Hollnagel E (1998) Cognitive reliability and error analysis method. Elsevier, Oxford 23. Gunderman RB (1998) Radiologic error. Essential Radiol 18:56鈥?8 24. Berlin L (2007) Radiologic errors and malpractice: a blurry distinction. AJR Am J Roentgenol 189:517鈥?22 CrossRef 25. Berlin L (2007) Accuracy of diagnostic procedures: has it improved over the past 5 decades? AJR Am J Roentgenol 188:1173鈥?178 CrossRef 26. Commissione Tecnica sul Rischio Clinico (2004) Analisi dei processi di cura per attivit脿: attivit脿 radiologica. Allegato 4A. In: Risk management in Sanit脿. Il problema degli errori. Ministero della Salute, Roma, pp.79鈥?4. rischio-clinico-28074.pdf" class="a-plus-plus">http://www.ministeerosalute.it/programmazione/qualit脿/Documenti/rischio-clinico-28074.pdf. Last access 30.6.2010 27. Arcuri V (2008) Risk management in Radiologia. Radiol Med 113:S79鈥揝80 28. Reason JT, Carthey J, de Leval MR (2001) Diagnosing 鈥渧ulnerable system syndrome鈥? an essential prerequisite to effective risk management. Qual Health Care 10(Suppl 2):21鈥?5 29. Reason J (2002) Combating omission errors through task analysis and good reminders. Qual Saf Health Care 11:40鈥?4 CrossRef 30. Vincent C (2001) Clinical risk management. BMJ Press, London 31. Vincent C (2006) Patient safety. Elsevier, Oxford 32. Leape LL (2008) Scope of problem and history of patient safety. Obstet Gynecol Clin North Am 35:1鈥?0 CrossRef 33. Leape LL (2009) Errors in medicine. Clin Chim Acta 404:2鈥? CrossRef 34. Sicurezza del Paziente e gestione del rischio clinico (2008) Manuale per la formazione degli operatori sanitari. Ministero della Salute, FNOMCeO, IPASVI. Biblioteca La professione, Anno X. http://www.salute.gov.it/imgs/C_17_pubblicazioni_640_allegato.pdf 35. Leape LL (1994) Error in medicine. JAMA 272:1851鈥?857 CrossRef 36. Leape LL (2002) Reporting of adverse events. N Engl J Med 347:1633鈥?638 CrossRef 37. Leape LL, Berwick DM (2005) Five years after 鈥淭o Err is Human鈥? what have we learned? JAMA 293:2384鈥?39 CrossRef 38. Scally AJ, Brealey S (2003) Confidence intervals and sample size calculations for studies of film-reading performance. Clin Radiol 58:238鈥?46 CrossRef 39. Senders JW, Moray N (1991) Human error: course, prediction and reduction. Lawence Erlbaum Associates, Hillsdale NJ 40. Rasmussen J (1990) Human error and the problem of causality in analysis of accident. Philos Trans R Soc Lond B Biol Sci 327:449鈥?62 CrossRef 41. World Health Organization (2003) towards a common international understanding of patient safety concepts and terms: taxonomy and terminology related to medical errors and system failures. a report of a WHO Working Group Meeting, Geneva 42. Nashef SA (2003) What is a near miss? Lancet 361:180鈥?81 CrossRef 43. Berlin L (1996) Malpractice issues in radiology. Perceptual errors. AJR Am J Roentgenol 167:587鈥?90 44. Kopans MD, Daniel B (2004) Mammography screening is saving thousands of lives, but will it survive medical malpractice? Radiology 230:20鈥?4 CrossRef 45. Piattelli Palmarini M (1996) L鈥檌llusione di sapere. Editore Mondadori, Milano 46. Berbaum KS, Franken EA, Hesson W et al (1988) Impact of clinical history on fracture detection with radiography. Radiology 168:507鈥?11 47. Norman GR, Brooks LR, Coblentz CL, Babcook CJ (1992) The correlation of feature identification and category judgements in diagnostic radiology. Mem Cognit 20:344鈥?55 48. Berlin L (2000) Malpractice issues in radiology. Alliterative errors. AJR Am J Roentgenol 174: 925鈥?31 49. Berlin L (2000) Malpractice issues in radiology. Pitfalls of the vague radiology report. AJR Am J Roentgenol 174:1511鈥?517 50. Fileni A (2008) Esiste in Italia la volont脿 della vera conoscenza del rischio clinico e di quello specifico radiologico? Il Radiologo 3:211鈥?13 51. Smith JJ, Berlin L (2001) Picture archiving and communication systems (PACS) and the loss of patient examination records. AJR Am J Roentgenol 176:1381鈥?384 52. American College of Radiology (1999) ACR standard for digital image data management. In: Reston VA (ed) Standards 1999鈥?000. American College of Radiology, Reston, pp 15鈥?2 53. D. Lgs 30 giugno 2003 n. 196 (2003) Codice in materia di protezione dei dati personali. Gazzetta Ufficiale n. 174 del 29 luglio 2003-suppl ordinario n. 123. Per il contenuto del documento programmatico sulla sicurezza si veda l鈥檃llegato B al punto 19 54. Channin D (2001) Integrating the healthcare enterprise: a primer part 2 (seven brides for seven brothers: the IHE Integration profiles). Radiographics 21:1343鈥?350 55. IHE IT Technical Framework.http://www.ihe.net/Technical_Framework/upload/IHE_ITI_TF_5-0_Vol1_FT_2008-12-12.pdf. Last access 30.6.2010 56. National Electrical Manufacturers鈥?Association (NEMA) Digital Imaging and Communication in Medicine (DICOM). http://www.nema.org/stds/dicom.cfm 57. Moore S (2003) Using the IHE scheduled Work Flow Integration profile to drive modality efficiency. Radiographics 23:523鈥?29 CrossRef 58. IHE RAD Technical Framework (2008) http://www.ihe.net/Technical_Framework/upload/ihe_tf_rev8.pdf. Last access 30.6.2010 59. D. Lgs 7 marzo 2005 n. 82 (2005) Codice dell鈥檃mministrazione digitale. Gazzetta Ufficiale n.112 del 16 maggio 2005 鈥?supplemento ordinario n. 93 60. Di Denia P (2004) La Fmea/Fmeca: un metodo proattivo per la riduzione dei rischi. In: Cinotti R, La gestione del rischio nelle organizzazioni sanitarie. Il Pensiero Scientifico, Roma 61. Lilford RJ, Mohammed MA, Braunholtz D, Hofer TP (2003) The measurement of active errors: methodological issues. Qual Saf Health Care 12:ii8鈥搃i12 CrossRef 62. Albolino S, Tartaglia R, Amicosante E, Liva C (2008) Incident Reporting Systems: the point of view of clinicians in the Italian hospitals. Healthcare Ergonomics Systems and Patient Safety 鈥?International Conference, Strasbourg 63. World Alliance for Patient Safety (2005) Draft Guidelines for Adverse Event Reporting and Learning Systems, Report WHO 64. Cinotti R (2004) La gestione del rischio nelle organizzazioni sanitarie. Il Pensiero Scientifico, Roma 65. Gunderman RB, Applegate KE (2005) Managing risk: threat or opportunity? AJR Am J Roentgenol 185:43鈥?5 CrossRef
- 作者单位:R. Golfieri (1)
L. Pescarini (2) A. Fileni (3) R. Silverio (4) C. Saccavini (5) D. Visconti (6) G. Morana (7) M. Centonze (8)
1. U.O. Radiologia Malpighi, Dipartimento di Malattie Apparato Digerente e Medicina Interna, Azienda Ospedaliero-Universitaria di Bologna, Policlinico S. Orsola-Malpighi, Via Albertoni 15, 40138, Bologna, Italy 2. U.O. di Senologia, Istituto Oncologico Veneto, Padova, Italy 3. U.O. di Radiologia Sede INRCA di Roma, Roma, Italy 4. U.O. di Radiologia Ospedale della Misericordia, AUSL 9 Grosseto, Grosseto, Italy 5. Centro Veneto Ricerca e Innovazione per la Sanit脿 Digitale, Arabba, Italy 6. Dipartimento di Radiodiagnostica APSS di Trento, U.O. di Radiologia, Ospedale di Fiemme-Cavalese, Trento, Italy 7. U.O. di Radiologia, Ospedale Civile di Treviso, Treviso, Italy 8. Dipartimento di Radiodiagnostica APSS di Trento, U.O. di Radiologia, Ospedale S. Chiara di Trento, Trento, Italy
文摘
The present contribution, presented as an Editorial, addresses the issue of patient safety in Radiology: this topic, of great current National and Regional interest, has stimulated a strong focus on accidents and mistakes in medicine, together with the diffusion of procedures for Risk Management in all health facilities. The possible sources of incidents in the radiological process are exposed, due to human errors and to system errors connected both to the organization and to the dissemination of Information Technology in the Radiological world. It also describes the most common methods and tools for risk analysis in health systems, together with some application examples presented in Part II.
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