[Application of a pro-active method of risk analysis in communication among health personnel in an Italian medicine ward].

In the last decade health system stressed the question on patient's security as fundamental pre-requirement of health assistance and also on appropriateness and efficacy Aim of this study, conducted in the period November 2007-Genuary 2008, is the application of pro-active method (Health Failure Mode Effect Analysis - HFMEA) to analyze risks in communication among health personnel in a medicine ward of an Italian hospital. Communication is a error source: in some studies it was origin of 60% of adverse events that occurred in hospital accredited at excellence. HFMEA method permitted, throughout the work of a multidisciplinary team, a systematic approach to critical processes to decompose them and to recognize probability of occurrence and injure importance, permitting to define a Priority Index of Risk (RPI) with formula risk=probability of occurrence x injure severity. In the study results error modality at high risk were those regards to development of following activities: assistance activities without supervision of nurse, post meridiem activities in which admissions/recharges are concentrated in a short time, collection of informative consensus to haemo-transfusion, nocturne assistance. Middle risk processes were resulted: urgent admission, examination round, graphic manage. In conclusion with application of HFMEA, without needs of additional resources, critical points that determined frequently errors were defined throughout a positive and pro-active approach regards to health personnel. The method stress attention to knowledge of phenomenon and to analysis of error modality to permit the prevention.