Riassunto
Il termine “segnalazione” possiede molteplici significati ed è utilizzato in contesti assai diversificati, che vanno dall’evento senza danno al sinistro. Contengono segnalazioni le pagelle scolastiche, temute da tanti di noi, e preparate da un’autorità che, a seconda dei casi, appariva benevola, indifferente o malevola. Nelle accezioni più cupe la segnalazione assume le sembianze del Grande Fratello, della perfidia e della delazione. Tuttavia, la segnalazione è anche comunicazione positiva, informativa e necessaria. Contengono segnalazioni i notiziari sugli eventi che accadono nel mondo, i rapporti prodotti da organizzazioni e governi per informare (o nascondere) e anche, semplicemente, la narrazione di fatti accaduti e il resoconto di eventi. I numerosi tipi di segnalazione propri del sistema sanitario possono essere associati a tutti questi diversi significati, e ciò comporta notevole confusione e rende estremamente sospetti i tentativi di incoraggiare la segnalazione di errori, eventi clinici e problemi di sicurezza.
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Bibliografia
Abeysekera A, Bergman IJ, Kluger MT, Short TG (2005) Drug error in anaesthetic practice: a review of 896 reports from the Australian Incident Monitoring Study database. Anaesthesia, 60(3):220–227
Barach P, Small SD (2000) Reporting and preventing medical mishaps: lessons from non-medical near miss reporting systems. British Medical Journal, 320:759–763
Beckmann U, West LF, Groombridge GJ et al (1996) The Australian Incident Monitoring Study in Intensive Care: AIMS-ICU. The development and evaluation of an incident reporting system in intensive care. Anaesthesia and Intensive Care, 24(3):314–319
Benn J, Koutantji M, Wallace L et al (2009) Feedback from incident reporting: information and action to improve patient safety. Quality and Safety in Health Care, 18(1):11–21
Billings C (1998) Incident reporting systems in medicine and experience with the aviation reporting system. In: Cook RI, Woods DD, Miller CA (eds) A Tale of Two Stories: Contrasting Views of Patient Safety. US National Patient Safety Foundation, pp 52–61
Blais R, Bruno D, Bartlett G, Tamblyn R (2008) Can we use incident reports to detect hospital adverse events? Journal of Patient Safety, 4(1):9–12
Department of Health (2000) An Organisation with a Memory: Learning from Adverse Events in the NHS. The Stationery Office, London
Firth-Cozens J (2002) Barriers to incident reporting. Quality and Safety in Health Care, 11(1):7
Firth-Cozens J, Redfern N, Moss F (2004) Confronting errors in patient care: the experiences of doctors and nurses. Clinical Risk, 10:184–190
Hogan H, Olsen S, Scobie S et al (2008) What can we learn about patient safety from information sources within an acute hospital: a step on the ladder of integrated risk management? Quality and Safety in Health Care, 17(3):209–215
Holzmueller CG, Pronovost PJ, Dickman F et al (2005) Creating the web-based intensive care unit safety reporting system. Journal of the American Medical Informatics Association, 12(2):130–139
Leape LL (1999) Why should we report adverse incidents? Journal of Evaluation in Clinical Practice, 5(1):1–4
Medicines and Healthcare Products Regulatory Agency (2009) Yellow Card Scheme First Anniversary for Patient Reporting — Reports from the Public Up 50%. Medicines and Healthcare Products Regulatory Agency, London
Olsen S, Neale G, Schwab K et al (2007) Hospital staff should use more than one method to detect adverse events and potential adverse events: incident reporting, pharmacist surveillance and local real-time record review may all have a place. Quality and Safety in Health Care, 16(1): 40–44
Robinson AR, Hohmann KB, Rifkin JI et al (2002) Physician and public opinions on quality of healthcare and the problem of medical errors. Archives of Internal Medicine, 162(19):2186–2190
Runciman WB, Webb RK, Lee R, Holland R (1993) System failures: an analysis of 2000 incident reports. Anaesthesia and Intensive Care, 21:684–695
Runciman WB (2002) Lessons from the Australian Patient Safety Foundation: setting up a national patient safety surveillance system — is this the right model? Quality and Safety in Health Care, 11(3):246–251
Runciman WB, Williamson JAH, Deakin A et al (2006) An integrated framework for safety, quality and risk management: an information and incident management system based on a universal patient safety classification. Quality and Safety in Health Care, 15(Suppl 1):i82–i90
Sari AB-A, Sheldon TA, Cracknell A, Turnbull A (2007) Sensitivity of routine system for reporting patient safety incidents in an NHS hospital: retrospective patient case note review. British Medical Journal, 334:79
Scobie S, Thomson R, McNeil JJ, Phillips PA (2006) Measurement of the safety and quality of healthcare. Medical Journal of Australia, 184(Suppl 10):S51–S55
Smith AF, Goodwin D, Mort M, Pope C (2006) Adverse events in anaesthetic practice: qualitative study of definition, discussion and reporting. British Journal of Anaesthesia, 96(6):715–721
Stanhope N, Crowley-Murphy M, Vincent C et al (1999) An evaluation of adverse incident reporting. Journal of Evaluation in Clinical Practice, 5(1):5–12
United States National Patient Safety Foundation (2000) Agenda for research and development in patient safety. http://www.npsf.org/pdf/r/researchagenda.pdf
Vincent C (2007) Incident reporting and patient safety. British Medical Journal, 334:51
Wu AW, Provonost P, Morlock L (2002) ICU incident reporting systems. Journal of Critical Care, 17(2):86–94
Yong H, Kluger MT (2003) Incident reporting in anaesthesia: a survey of practice in New Zealand. Anaesthesia and Intensive Care, 31(5):555–559
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(2011). Sistemi di segnalazione e apprendimento. In: Tartaglia, R., Albolino, S., Bellandi, T. (eds) La sicurezza del paziente. Springer, Milano. https://doi.org/10.1007/978-88-470-1875-4_5
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