Ambiguità e aggiramento dei problemi come fattori contribuenti all’errore medico

Abstract

Administration of the wrong medication is a serious and understudied problem. This article analyzes two cases. The first one describes a patient with iatrogenic hypoglycemia due to administration of the wrong medication: insulin instead of heparin was used to flush the patient’s arterial line. In the second one a woman, who was admitted to a teaching hospital for cerebral angiography, mistakenly underwent an invasive cardiac electrophysiology study. The articles analyses strategies to improve patients safety focusing on how removing ambiguity and workarounds can be useful in preventing medication errors.