Promuovere il coinvolgimento dei pazienti per migliorare la sicurezza in chirurgia

Background: Patient safety has become essential with increasing complexity of health systems and the consequent increase in patient damage. Clinical risk management aims to prevent and reduce the risks, errors and damages that occur to patients during health care. The direct involvement of patients in care pathways can be both an important source of information on potential risks and a resource for improving safety.Objective: To improve patient safety in surgery by promoting the active involvement of patients admitted to an orthopedic department.Method: After check-in, a checklist was administered to the patients, consisting of 21 items that took into consideration the good practices to be applied in surgery. The checklists returned by the patients at the end of their stay were analyzed to identify any areas for improvement.Results: From July 2019 to September 2019, the checklists were administered to 76 patients who underwent hip or knee arthroplasty, admitted to an orthopedic ward. 63% of the delivered checklists were returned by the patients. The analysis made it possible to verify that good practices for safety in surgery are effectively applied by health personnel. However, some critical areas were identified on which to intervene with improvement actions.Conclusions: This work demonstrates that patient involvement can help improve the safety of the surgical path, in order to prevent potential adverse events. Further studies are needed with sufficient sample power to validate the findings of this work.

Limitazione della responsabilità sanitaria in tempi di emergenza da COVID-19

[Abstract non presente. Si riporta l'inizio dell'editoriale]Nell’odierno contesto storico, gravato da un’emergenza sanitaria senza precedenti, ci si domanda sotto quali forme la responsabilità medica debba essere inquadrata e quali siano le singole responsabilità che possano essere addebitate all’esercente la professione sanitaria, di cui all’art. 7 della legge 8 marzo 2017, n. 24, e alla struttura sanitaria...

La valutazione medico-legale delle ipoacusie in ambito assistenziale (invalidità civile e sordità civile) e previdenziale INPS

The authors address the issue of hearing loss assessment for civil incapacity and INPS social security disability benefits.The purpose of this work is to compile an easy-to-use handbook for the public and for doctors unfamiliar with legal medicine who need to address the complex issue of performing a medical-legal assessment of hearing loss for INPS social security disability and civil incapacity.General practitioners often incorrectly fill out INPS online application forms to obtain subsidies from Local Health Authorities (ASL / ASP) for the purchase of hearing aids for entitled citizens recognised as legally disabled due to loss of hearing.Frequently, instead of «civil incapacity», doctors select the term «legal deafness», introduced in 2006 as the legislative definition for deaf-mute individuals, i.e. persons with congenital deafness or hearing impairments acquired during childhood that have affected the normal learning of speech.

La valutazione della disabilità ai fini del riconoscimento dell’indennità di accompagnamento nel soggetto ultra-sessantasettenne

Older people, the fastest growing part of population, are at the highest risk of acquired disability or cognitive decline and, as a consequence, their claim to receive support services, among which the Attendance Allowance for permanent personal assistance, is increasing. This benefit was introduced in the Italian Civil Incapacity system with the law 18/1980 and some relevant innovations were added with the Law 508/1988 and the Decree 509/1988. From a medico-legal point of view, these regulations, define on the one hand the necessary requirements to get a pension (non-contributory), that is physical and or mental disease determining the incapacity for work and, for infra-18 and over-65-year olds, require the “persistent difficulties” to carry out the “tasks and activities” proper to their age. On the other hand, the Law n. 508/1988 identifies also the necessary conditions to get the Attendance Allowance, for those who are unable to get around and/or are unable to carry out daily life activities without the permanent help of a caregiver.Therefore, these regulations specifically provide, first of all, the recognition of the highest level of severity of the “persistent difficulties” concerning the “tasks” and “activities” of the over 65s (prerequisites) and then the judgment for the Attendance Allowance. However, there are considerable difficulties with the assessment of this kind of disability. In fact, we have specific references about incapacity for work indicating the evaluation path and the guide for the rating of permanent impairment (Ministerial Decree 5 February 1992), but there aren’t specific normative and assessment indications about the ability to perform “tasks and activities” in over-65-year-olds (age requirement has become over 67s since January 2019) which allows the risk of a wide evaluating discretion.Italian institutions, like Ministry of Health or INPS (Italian Institute of Social Security) and others officially involved, have attempted to explain and clarify the above-mentioned rating process, but with unsatisfactory results and in some cases even with regressive ones, producing real distortions and interpretative stretches. The author, therefore, after presenting the medico-legal issues for the evaluation of older adults’ disability based on the current regulations, also criticizes the widely found practice of using an atypical, not multidisciplinary, comprehensive geriatric assessment made only for this purpose and elaborate by a single specialist. In fact, the results of a geriatric assessment, like any other Health Certification, is useful to complete the medical history of the subject alleging disability and, therefore, it must be validated by a proper and extensive medico-legal evaluation.

Evoluzione metodologica dell’invalidità civile in Italia: confronto ragionato tra i sistemi valutativi tabellari, di legge e non, che si sono succeduti negli anni

The authors describe the evolution from 1980 to the present of the tables that describe invalidating states, on which the medical-legal judgments of civil disability in Italy are based.The first part of the work briefly describes the main disabilities, grouped by both body system and percentage value range, that can be found in the tables attached to the main documents applied, or applicable, to the sector: those issued alongside the Ministerial Decree n. 282 of 1980, those that accompanied the Ministerial Decree of February 1982 (still in force today) and those proposed by the Italian Institute of Social Security (INPS) in 2012, which have not yet entered into force.The second part of the paper has two aims. On the one hand, it seeks to underline the change in the pre-eminent type of disability featured in the tables: from osteoarticular diseases, which were the most significant type in the 1980 tables, to neoplastic diseases, which are the most prevalent overall in the 2012 tables.On the other hand, the authors highlight that the tables themselves have evolved, moving towards a more precise definition (both clinical and instrumental) of the organ damage causing the reduction in general working capacity. In the 1980 tables, disability was often evaluated empirically rather than based on the use of functional indices or systematic classification. In the 2012 INPS proposed tables, evaluations of the reduction in working capacity are often based on specific functional parameters for the various organs (EF for the heart, FEV1 for the respiratory system, GFR for the urinary system) or on standardized disability evaluation scales (NYHA classes for heart diseases, EDSS or the Hoehn & Yahr classification for neurological disorders, MMSE or CDR for dementia, the Child-Pugh classification for cirrhogenic hepatopathies).

Morire di contenzione: riflessioni di deontologia e di infermieristica legale sulla vicenda di Francesco Mastrogiovanni

Talking about physical containment, in a nursing framework, means exploring a particular world, with many “I would like, but I can not”, that often speaks us about the moral and professional distress of the team involved in the “containment process”, because this, in fact, limits the freedom of the assisted person. And this limit of rights, jarring with nursing values, often represents a perceived “necessary pain” in different nursing settings.Organizational asphyxia, lack of motivation about change, ineffective leadership, knowledge deficits, lack of role identities and awareness are often promoters of incessant dangerous conditions, which turn procedures from “necessary pain” into real crimes.Francesco Mastrogiovanni’s story is, unfortunately, the proven evidence that the malign and uncritical customs have dramatic consequences

Il PDTA-HIV nella gestione del paziente cronicizzato: una proposta di documento condiviso

[Clinical / care pathways in the management of the chronically ill patient with HIV: proposal for a shared document]Abstract non presente. Si riporta l'inizio dell'editoriale La malattia HIV/AIDS ha visto nell’ultimo periodo un radicale cambiamento nelle prospettive di vita delle persone HIV+ e con esso il delinearsi di uno scenario del tutto differente rispetto alle loro esigenze ed aspettative...

La mediazione trasformativa nell’era della patient revolution. Un modello per la gestione del rischio clinico e legale nelle ASL italiane

[Transformative mediation in the era of the patient revolution. A model for the management of clinical and legal risk in Italian health facilities]Nowadays, too many patients do not perceive that their doctors are exclusively dedicated to care them. This is probably because current health systems are too focused on physicians and diseases, rather than on patients. Such systems are also expensive, fragmented, inefficient and often cynical, generating not only the anger but also the willingness to bring legal claims from many patients. Many scholars, in fact, claim that "too much medicine" can bring more harm than good to the patients and to the health systems themselves, therefore promoting a more sober and respectful medicine. This is the vision of the "patient revolution" and the idea that inspires some other movements that aim to break the vicious circle of greed and cynicism that damages not only patients but also health professionals. Within the same vicious circle, an exponential increase in litigations takes place, as an additional negative effect of the system focused on the disease and on the doctors instead of on the patient.In the present article, we assume that a greater participation of the patient in the choices concerning his/her own health is the fertile ground in which concrete solutions can be found to many problems arising from the current medicine. We therefore analyze the main advantages of active patient participation, which in turn generate a reduction in health conflicts. Based on this analysis, we propose a model in which through various approaches, tools and methods - starting from the upstream prevention of the conflicts - we can also manage them downstream, for the benefit of both patients and health professionals. Finally, we show that within this framework, transformative mediation is an essential approach for weakening many legal disputes and repairing the relational damage generated upstream, where communication has failed or is completely lacking in the clinical practice.

Compiti e funzioni del medico competente e modalità di svolgimento della professione alla luce della legislazione vigente

[The competent physician for the assessment of risks at work: tasks, functions and conduct in the light of current legislation]Abstract non presente. Si riporta l'inizio dell'editorialeNella normativa italiana già con il Regio Decreto 530 del 1927 all’art. 6 viene introdotta la figura del medico di fabbrica, e precisato che nelle lavorazioni industriali nelle quali si adoperino o si producano sostanze tossiche o infettanti indicate in un apposito elenco i lavoratori dovranno essere visitati da un medico competente...

"Malasanità": breve osservazione a proposito di un singolare quesito posto ai Consulenti Tecnici d’Ufficio in un caso di accertamento tecnico preventivo ex art. 8 della cosiddetta Legge Gelli-Bianco

["Malasanità": brief observation on a singular question posed to Technical Consultants in a case of prior technical assessment pursuant to art. 8 of the so-called Legge Gelli-Bianco]Abstract non presente. Si riporta l'inizio dell'editoriale Nel luglio del 2018 il Giudice di un Tribunale riceveva istanza di accertamento tecnico preventivo ex art. 8 della cosiddetta Legge Gelli Bianco (Legge n. 24/2017) [1], che, come è noto, impone, a chi voglia esercitare di fronte al Giudice «un’azione risarcitoria derivante da responsabilità sanitaria, di tentare prima un percorso negoziale al fine di verificare la possibilità di evitare il processo» [2]. Nel caso in questione, il Giudice adíto, ai Consulenti Tecnici d’Ufficio (CTU) nominati poneva il seguente quesito: «Accertare l’entità delle lesioni e postumi permanenti residuate al signor XY a seguito dellamala sanità, il nesso di causa tra le lesioni lamentate e l’operato dei sanitari Usl, nonché la congruità delle spese mediche, la necessità di spese mediche future in modo da addivenire ad una composizione della lite».