Riassunto
La pubblicazione nel 1999 del rapporto “To err is human: building a safer health system” [1] da parte dell’autorevole Institute of Medicine, determinò un notevole aumento di interesse dei mass media sugli errori in medicina. Forse per la prima volta, pubblicamente e presentando degli studi su riviste accreditate, i medici statunitensi dichiaravano che, a seguito di loro errori, ogni anno morivano molte migliaia di pazienti. Era necessario, per questo, introdurre un nuovo modo di affrontare il problema, la cultura della colpa non rendeva più sicuri i sistemi sanitari. Era necessario favorire la segnalazione degli eventi avversi, poter apprendere dalla loro analisi e dare così una memoria alle organizzazioni migliorandone processi e procedure.
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Tartaglia, R., Ninu, M.B. (2011). Risk management. In: Tumori della testa e del collo. Springer, Milano. https://doi.org/10.1007/978-88-470-1806-8_2
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