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Medical error and systems of signaling: conceptual and linguistic definition

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Abstract

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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Notes

  1. An error is the failure in planning or in performance of a sequence of actions that determines the failure to achieve, not attributable to chance, the desired objective [6]. In the case that an error is the cause of damage to the patient, we talk about an adverse event that is an unexpected event related to the care process which leads to damage to the patient, unintentional and undesirable. Not all adverse events are due to error. An adverse event is the consequence of error only if there was some kind of deficiency or lack of care by the medical staff, or if they could have somehow avoided the damage, despite not intending to produce it. A potential adverse event can be defined as a missed adverse event, (a near miss or a close call and is an error that has the potential to cause an adverse event that does not occur because of unforeseeable circumstances or has been intercepted, or because it has no adverse consequences for the patient [7]. The Sentinel event is a particularly serious adverse event, potentially indicative of a serious system malfunction, which can result in death or serious damage to the patient, and that causes a loss of public confidence in the health service.

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Smorti, A., Cappelli, F., Zarantonello, R. et al. Medical error and systems of signaling: conceptual and linguistic definition. Intern Emerg Med 9, 681–688 (2014). https://doi.org/10.1007/s11739-014-1108-1

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