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Fattore umano in chirurgia
- 1. HUMAN FACTOR IN SURGERY Emilio Gentile Warschauer Roberto Tamburini
- 3. CRM Outcomes C.Serafinelli - R.Tamburini TEM
- 9. ACCIDENTS INCIDENTS ERRORS (UNREPORTED OCCURRENCES)
- 10. Fortunately, not all events become accidents… Serious incident Routine occurrence Accident Statistical event Significant event Flight Safety Foundation, 2006; Adapted with permission. … but events/occurrences can lead to incidents and accidents 1 10 30 200 600
- 15. 26/10/11 i.e. Scarso addestramento,manuali carenti.
- 21. Medical situation C.Serafinelli - R.Tamburini MCC Course
Notes de l'éditeur
- Errors = building blocks of tomorrow’s accidents and incidents; esp. when they happen in conjunction with other blocks in this part of pyramid
- The BASIS risk model is a well established model which illustrates that there are many more minor events and routine occurrences than the more significant events and isolated accidents. In practice, these lesser events may be unreported or treated as part of normal operations. It is by the proactive control of the trends within these numerous less serious events that the possibility of an accident can be reduced to a minimum. This forward-looking philosophy allows preventive measures to be taken before the trend has escalated to a significant event. The Flight Crew reports and the DFDR monitoring or FOQA program are essential parts of establishing enough information to control the significant trends and reduce the company’s exposure to risk and liability.