Articolo speciale
Imparare dall'errore
LEARNING FROM ERRORS
G. Bertolini
Febbraio 2010 - pagg. 100 -102
Abstract
Physicians are trained within a cultural framework in which the main emphasis is toward the
correctness and precision of what is known. The areas of uncertainty are seldom made clear
and medical error is more or less implicitly considered unacceptable. Nevertheless, errors are
always possible and even unavoidable. Hence, the ability to learn from errors must be developed,
particularly by health professionals. To reach such a goal, a new culture that does
not ban errors as markers of failures of which to be ashamed - bad things happen to bad
people - should be promoted. This way, the problem would move from exculpating/
condemning people to understanding reasons that have led someone to err. Whilst the
main concern should remain to avoid errors, the best way to obtain this is to deeply know factors
that facilitate them.
Classificazione MeSH
Bibliografia
1. Debenedetti E. Conoscenza ed errore in
medicina. Torino: Minerva Medica, 1959.
2. McIntyre N, Popper K. The critical attitude in medicine: the need for a new ethics. BMJ (Clin Res Ed) 1983;287:1919-23.
3. Wu AW, Folkman S, McPhee SJ, Lo B. Do house officers learn from their mistakes? JAMA 1991;265:2089-94.
4. Jastrow J. Storia dellerrore umano. Verona: Mondadori, 1945.
5. Geymonat L. Filosofia e filosofia della scienza. Milano: Feltrinelli, 1980.
6. Levi A. Il problema dellerrore nella filosofia neo-criticista. Milano: Hoepli, 1931.
7. von Weizscker E, von Weizscker C. Come vivere con gli errori? Il valore evolutivo degli errori. In: Ceruti M, Laszlo E (Eds). Physis: abitare la terra. Milano: Feltrinelli, 1988, p. 126-38.
8. Reason J. Human error: models and management. BMJ 2000;320:768-70.
9. Sexton JB, Thomas EJ, Helmreich RL. Error, stress, and teamwork in medicine and aviation: cross sectional surveys. BMJ 2000;320: 745-9.
10. Leape LL. Error in medicine. JAMA 1994; 272:1851-7.
11. Rosaia L. Lincertezza della medicina. Le Scienze 1986;209:32-9.
12. Barach P, Small SD. Reporting and preventing medical mishaps: lessons from nonmedical near miss reporting systems. BMJ 2000;320:759-63.
13. Nordio S. Perinatologia. Convivere con gli errori. Medicina e morale 1992;1:11-25.
14. Kohn L. Corrigan J, Donaldson M (Eds). To Err Is Human: Building a Safer Health System. Washington: National Academy Press, 2000.
2. McIntyre N, Popper K. The critical attitude in medicine: the need for a new ethics. BMJ (Clin Res Ed) 1983;287:1919-23.
3. Wu AW, Folkman S, McPhee SJ, Lo B. Do house officers learn from their mistakes? JAMA 1991;265:2089-94.
4. Jastrow J. Storia dellerrore umano. Verona: Mondadori, 1945.
5. Geymonat L. Filosofia e filosofia della scienza. Milano: Feltrinelli, 1980.
6. Levi A. Il problema dellerrore nella filosofia neo-criticista. Milano: Hoepli, 1931.
7. von Weizscker E, von Weizscker C. Come vivere con gli errori? Il valore evolutivo degli errori. In: Ceruti M, Laszlo E (Eds). Physis: abitare la terra. Milano: Feltrinelli, 1988, p. 126-38.
8. Reason J. Human error: models and management. BMJ 2000;320:768-70.
9. Sexton JB, Thomas EJ, Helmreich RL. Error, stress, and teamwork in medicine and aviation: cross sectional surveys. BMJ 2000;320: 745-9.
10. Leape LL. Error in medicine. JAMA 1994; 272:1851-7.
11. Rosaia L. Lincertezza della medicina. Le Scienze 1986;209:32-9.
12. Barach P, Small SD. Reporting and preventing medical mishaps: lessons from nonmedical near miss reporting systems. BMJ 2000;320:759-63.
13. Nordio S. Perinatologia. Convivere con gli errori. Medicina e morale 1992;1:11-25.
14. Kohn L. Corrigan J, Donaldson M (Eds). To Err Is Human: Building a Safer Health System. Washington: National Academy Press, 2000.
Corrispondenza: bertolini@marionegri.it