Organizzazione e Formazione per l’arresto cardiaco in ospedale Overview Epidemiologia dell’ arresto intraospedaliero Criticita’ organizzative Applicazioni pratiche La Teoria del “Crisis Resource Management” La Formazione La Rilevazione dei dati
PROGETTO A.C.R.O. Ma è sufficiente intervenire ? Ovvero : “ Quando la morte è un evento avverso”
L’approccio sistemico Alcuni buchi sono dovuti a errori attivi Altri sono dovuti a condizioni latenti (resident ‘pathogens’) Hazards Losses Reason, 2002 Il modello teorico
Riskmanagement Controllo del rischio Risk assessment Identificazione del rischio Analisi del rischio
LT Kohn. IOM Report
3.7% of hospitalized pts incurred disabling injuries 65% caused by errors potentially preventable the chances of dying from a preventable injury when a person entered a hospital were 1 in 300. by comparison, the risk of accidental death for a person boarding a US or European airliner is 1 in 3,000,000. a hidden epidemic, causing more deaths per year than automobile accidents, AIDS, or breast cancer.
The lesson is obvious: if you want to decrease medical injury you had to reduce errors How do you do that?
System theory tells us that it is not any one event that produces an error but rather the culmination and interaction of multiple events. Until the results of the Human Genome Project can be applied and we can build a better human being, we are going to have to build better systems. That is where the improvements must be made.
A four-part plan to reduce errors in health care Part 1: A center for patient safety Part 2: Error-reporting systems (Mandatory and Voluntary) Part 3: Setting performance standards Part 4: Creating a culture of safety in health care