[The clinical risk management: an initial experience of incident reporting in a surgical department]

With the aim of adverse events monitoring in a critical care area, an initial experience of a near miss events registration in a department of surgery at Fondazione IRCCS Cà Granda Ospedale Policlinico di Milano is reported in this article. A period of time of two weeks for the anonymous compilation of reporting forms has been scheduled. Data derived from this survey focused the attention on two main problems: the drug prescribing and administration errors and those related to the clinical management of the patient. The second main issue that deserves to be discussed is the incident reporting interruption during the second week, due to a perception of futility of this procedure still linked to a mentality not adequately prepared to learn from errors. The thinking about adverse events has shifted from the person approach-blaming individuals for errors-to the system approach. The experience here reported underlines the importance of training courses and adequate preparation of health personnel on the aims and how to communicate an adverse event, in order to resume an effective and continuous incident reporting activity in a critical care area.