Riassunto
Si imputano abitualmente all’errore umano gli incidenti aerei o ferroviari, e quelli che si verificano nella chirurgia complessa e in generale nell’assistenza sanitaria. Subito dopo un incidente la gente esprime giudizi affrettati e, fin troppo spesso, condanna la persona più evidentemente associata al disastro. Il pilota di un aereo, il medico che ha fatto l’iniezione, il conducente del treno che è passato con il semaforo rosso, vengono rapidamente identificati. Tuttavia, questi giudizi frettolosi e la condanna d’ufficio ci impediscono di scoprire la “seconda storia” (Cook et al., 1998), cioè la storia nella sua piena ricchezza e complessità, come emerge solo dopo un’indagine attenta e approfondita. Sebbene una singola azione o omissione possa essere la causa immediata di un incidente, un’analisi più attenta rivela in genere una serie di eventi e deviazioni dalle procedure sicure, ciascuno influenzato dall’ambiente di lavoro e dal più ampio contesto organizzativo (Vincent et al., 1998).
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(2011). Errore umano ep en siero sistemico. In: Tartaglia, R., Albolino, S., Bellandi, T. (eds) La sicurezza del paziente. Springer, Milano. https://doi.org/10.1007/978-88-470-1875-4_7
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