Approccio sistematico all’errore umano nella diagnostica per immagini

Abstract

We propose a systematic approach to human errors in radiology. We consider perceptual, cognitive and system errors. Practical aspects with psychological and clinical involvement are discussed with tree diagrams.

Clinical Risk Management in radiology. Part I: general background and types of error and their prevention

“…Satisfaction of search: the error is due to failure to dolo soddisfatto del suo operato. Sull'argomento sono stati elaborati numerosi test con lesioni di disturbo, con la verifica, sperimentata, dell'impatto negativo di più lesioni in un unico studio [21] [21]. b.…”

“…These fall into the three categories listed above (skill-based, rule-based and knowledgebased). Rule-based and knowledge-based errors are the result of various causes and are grouped under the umbrella term "psychological errors" [21]: a. Errors based on intellectual skills (skill-based): These include slips and lapses.…”

“…A specific psychological error related to framing may occur within screening settings. Quality indicators in screening mammography, such as reduced recall rates, influence the radiologist who may underestimate some minimal signs or signs of presumed benignity and fail to recall the woman [21]. "Failure to recall" may be considered an error due to distorted judgement, which only double reading or the help of computer-assisted diagnosis (CAD) systems may reduce.…”

“…In radiology, the first step is to become aware of the errors and adverse events that may occur during diagnostic activity: in daily practice, around 3%-5% of radiological interpretations contain errors, but risks and possible adverse events may be identified at all levels of a radiological process. The many literature reviews on the main causes of errors describe risks related to problems of technique, perception, knowledge, evaluation and judgement, communication and interventional radiology procedures [7,[18][19][20][21][22][23][24][25][26][27]. A recent survey conducted on a sample of 206 Italian radiologists reported that the factors contributing to error in radiology were, in order of consensus, excessive workload come indice di una sanità in crisi, ma piuttosto è il risultato dell'evoluzione della relazione medico-paziente, che -da decenni -è caratterizzata dallo sgretolamento del rapporto di fiducia (conseguente alla mutata percezione sociale della disgrazia-malattia e della potenzialità della medicina, ritenuta infinita) e dall'aumento dei contenziosi, indipendentemente dalla qualità del sistema sanitario.…”

“…Move to a model in which accountability is universal and reciprocal, not top down. Several fundamental principles and individual and system strategies for addressing and preventing risk are shown in Tables 1 and 2. All healthcare organisations have received guidelines for the development of preventive risk analyses, which incorporate spontaneous incident reporting of near misses or accidents [sentinel events (SE)] (Table 3) as a means to "sterilise" potentially dangerous situations, combined with actions to support professionals who adopt open organisalegati a: problemi tecnici, di percezione, di conoscenza, di valutazione e di giudizio, di comunicazione e correlati a procedure di radiologia interventistica [7,[18][19][20][21][22][23][24][25][26][27]. Una recente inchiesta condotta su di un campione di 206 radiologi italiani sui fattori che concorrono a determinare l'errore in radiologia riporta, in ordine di consenso, i ritmi di lavoro eccessivi (vengono definiti "molto importanti" dal 67% degli intervistati), i tempi insufficienti per la refertazione (88,6%), la mancata possibilità di consultare i colleghi ( [28][29][30][31].…”