[Risk management in coronary care units].
The clinical risk management is a very important tool to make safer the medical health system. The first step is a cultural change: the error is a human factor, all persons involved in the health system delivery are prone to erring: in order to reduce it, we have to learn from the error in order to know not who err but why an error occurs. The error must loose its ethical value (non blame culture) to become the starting point of a process that allow us to look into the mechanisms of the error, to detect the active or latent causes, to understand the weak points of our care delivering organization, to plan the appropriate measures against the occurrence of new adverse events. The reactive (from error to prevention) and proactive (before an adverse event occurs) approaches are the two methods mostly used when performing clinical risk management; the most useful tools to perform this kind of analysis are incident reporting, root cause analysis, clinical audit, and hospital failure mode and effect critically analysis. The intensive cardiac care unit is a hospital department that more needs to implement the culture of clinical risk management because of the use of ever new diagnostic and therapeutic tools, the importance of team working and of the technical and clinical skill, the complex case mix of patients. Therapy and clinical diary sheet, and team organization are some of the most important elements that we can improve even without a specific skill in risk management. The use of check lists and diagnostic and therapeutic flow-charts is useful in helping less skilled physicians to manage critically ill patients. Examples of preventive actions in the setting of an intensive cardiac care unit are provided.
Mafrici
Antonio
A
Unità di Terapia Intensiva Cardiologica, Dipartimento di Cardiologia "A. De Gasperis", A.O. Ospedale Niguarda Ca' Granda, Milano. antomafrici@libero.it
D003325:Coronary Care Units / Q000592:standards*; D003422:Critical Care / Q000592:standards*; D006801:Humans; D007558:Italy; D019300:Medical Errors / Q000517:prevention & control*; D011322:Primary Prevention; D012308:Risk Management / Q000379:methods / Q000592:standards / Q000639:trends