• Non ci sono risultati.

Letture su invito Sessioni Plenarie SIBioC-SIMeL


Academic year: 2021

Condividi "Letture su invito Sessioni Plenarie SIBioC-SIMeL"


Testo completo



RIMeL / IJLaM 2008; 4 (Suppl.)

Letture su invito Sessioni Plenarie SIBioC-SIMeL

Error in medicine ... 108 L.L. Leape

Teaching Evidence Based Laboratory Medicine: How to spread the word? ... 109 R.H. Christenson

Clinical Governance and Evidence Based Laboratory Medicine ... 111 T. Trenti

Evidence-Based Laboratory reporting to clinicians ... 112 D. Giavarina

“Universal definition of myocardial infarction”: le nuove linee-guida 2007 ... 113 M. Galvani

High sensitive methods for cardiac troponin assay: analytical characteristics and pathophysiological

aspects ... 115 A. Clerico, C. Prontera

Quality specifications in cardiac biomarkers assays: which updatings? ... 116 M. Zaninotto

Cardiovascular markers: what does it change in the routine daily care of patients with new

“gold standard”? ... 117 M. Cassin, D. Rubin

Standardization in Laboratory Medicine: activities, goals, and further issues ... 118 M. Panteghini

Standardisation of HbA


Measurements: practical consequences and course of activation ... 119 A. Mosca

Will standardization assist best practice in thyroid function testing? ... 120 G.H. Beastall

La standardizzazione in ematologia ... 121 M. Buttarello

A new laboratory in a new hospital: chronicle of an experience ... 124 I. Bertoli

The reorganization of medical laboratory. The plan from the region of Sardinia ... 125

N. Camusso


RIMeL / IJLaM 2008; 4 (Suppl.)


Ricevuto: 03-09-2008 Pubblicato on-line: 13-10-2008

Corrispondence to: Dr. Lucian L. Leape, Harvard School of Public Health, Boston, Massachusetts, USA

Error in medicine

L.L. Leape

Harvard School of Public Health, Boston, Massachusetts, USA

Studies from the early 1990’s suggested that 3-4% of patients hospitalized in America suffered an injury caused by their treatment, and that more than half of these inju- ries were caused by errors or systems failures. It was esti- mated that as many as 98,000 people die annually in U.S.

hospitals because of medical errors. If the same rates ap- ply in Italy, 19,000 people die needlessly in Italian hospitals every year. The American studies have since been repeated in 6 other countries, where the average rate of injury has been found to be close to 10%, suggesting the problem is even worse than imagined.

Studies from cognitive psychology and human factors engineering, as well as everyday life experience, show that errors are normal part of human existence. But studies also show that most errors result from faulty systems, not from carlessness or incompetence. That is, the design of the tasks and processes that we work in leads us to make

mistakes. For example, two medication containers that have similar appearing labels are an invitation to a mix-up. Re- quiring a nurse or a doctor to work a full shift after they have just been awake working all night increases the chan- ce they will make a mistake. Excessive work loads make errors more likely. To prevent errors, the systems need to be redesigned. This is what commercial aviation has done with such great success.

This is what health care must do.

A major effort is underway around the world to redesi-

gn health care systems to improve patient safety. A num-

ber of new safe practices have been developed that will

significantly reduce medical errors. They now need to be

implemented widely in hospitals. This is part of the mis-

sion of the World Alliance for Patient Safety. Other exam-

ples of recent successes will be described. The time has

come for a world-wide effort to reduce medical mistakes.


Documenti correlati

By using a loss of function approach in Xenopus embryos I demonstrated in vivo, for the first time, the capacity of serotonin, via 5-HT2B receptor, to act as a

Presiede: Dario Miccoli (Università Ca’ Foscari Venezia) Discutono: Rosita Di Peri (Università di Torino),. Matteo Legrenzi (Università Ca’

In fact, all the empirical parts of the thesis have been done using aggregate data of the Euro Area, implying that the monetary policy suggestions derived may be helpful for

Sono i due nuovi coinquilini della vecchia casa di Thomas e Emma, che sentono “the piano playing / Just as a ghost might play”, infatti, il poeta

This work proposes a novel releasing strategy that makes use of the capillary force also to release the micropart, in particular it exploits the different surface tension of the

However the uncertainty on the experimental PMTF has been esti- mated by performing eight independent measurements of the MTF. The error due to the phase effect has been taken

Urinary Albumin Excretion in chronic kidney disease: critical issues in measurement and

The frequency separation between the reference laser and the + laser beam is measured with a Fabry-Perot spectrum analyzer and the ring laser perimeter length is corrected in order

The main contribution of this paper is to provide a complete analysis of the trade-off between performance and information flow in the simple case of the stabilization of a scalar

Automotive industry was followed respectively by Clothing and Apparel Sector with 10,5 percent (17 billion 642 million 157 thousand dollars), Chemical Materials and

) No monitoring therapy will improve any patient outcome unless linked to a relevant clinical protocol or therapeutic target. This is especially important as many clinical studies

Although music is not restrained to the human species and a number of nonhuman creatures produce music, especially birds and cetaceans, music appears as a unique characteristic

The International Classification of High-Resolution Computed Tomography for Occupational and Environmental Respiratory Diseases is a powerful and reliable tool for

10 | American Journal of Public Health Heines | Peer Reviewed | Faces of Public Health | 1687 state mental hospitals to horrible..

Throughout, I argue that pragmatic considerations, and not basic principles, are the primary remaining objections to actively hastening one’s death; that these practical

It is apparent from the table that low-income countries could save annually 12–24% of their total health spending by improving hospital or workforce efficiency,

Examples of variable costs include products needed for handwashing, including soap, water, and materials used for drying hands (e.g. towels), while the costs of hand antisepsis

Call to Action for European decision-makers, towards strong health workforces and sustainable health systems around the world.. Signatures of 175 key actors have been collected

equitabl e approp riate effe ctive acce ssible ac ceptable equitabl e approp riate effe ctive acce ssible ac ceptable equitabl e approp riate effective accessibl e accepta ble

(..mi chiederanno i miei amati lettori…. ) Essere ha due caratteristiche che lo rendono non proprio facilissimo….. 2)..per formare i tempi composti, in Italiano, utilizza le sue

y international copyright laws.No additional reproduction is authorized.It is permitted for personal use to download and save only one file and print only one copy of this Article.It

regole comunitarie antitrust: “La dichiarazione di inapplicabilità riguarda unicamente le seguenti attività: a) le operazioni relative all'esercizio in comune di servizi

We find also that when the rate of energy produced by the DM annihilations and absorbed by the gas equals the chemical cooling (at densities yet far from the actual formation of