Proactive evaluation of clinical risk: a FMECA analysis in pediatric chemotherapy.

In 2010-2011, we used FMECA to prospectively assess risk-management in chemotherapy of children with cancer, in a third level Italian children's Hospital (Ospedale Pediatrico Bambino Gesù; OPBG). We designed a flow chart representing the entire process; we described potential failure points for each step of the process, as well as their potential underlying causes. We calculated the risk priority number (RPN) of each failure point based on the severity of the failure, the frequency of occurrence, and the likelihood of detecting the failure prior to completion of the process. All FMECA activities were supported by a web-based tool. The highest RPN values were observed for failure points of the paper-based chemotherapy medication orders sent from clinicians to Pharmacy, the transcription of the orders into the Pharmacy paper-based work-sheet for medication preparation, and the selection of medications to be used for chemotherapy preparation. Causes of these failures were mostly related to illegible or incomplete handwriting. As a consequence of these results, the implementation of an electronic ordering process for children's chemotherapy medications was proposed as risk-reducing action.

[Observational Team work Assessment for Surgery as Quality and Safety improvement tool]. / Il metodo osservazionale della capacità di lavorare in gruppo dell'equipe chirurgica: le OTAS (Observational team work Assessment for Surgery) quale strumento di migliormento della qualità e della sicurezza delle cure.

As in high reliability systems , also in surgery the causes of adverse events are primarily correlated to deficiencies in Non Technical Skills (individual and social skills), that contribute with Technical Skills to a safe surgical procedure. Non Technical Skills are cognitive behavioural and interpersonal abilities, that are not specific to the expertise of one profession, but very important to guarantee the patient safety and to reduce risk of errors and adverse events. The Observational Teamwork Assessment for Surgery (OTAS) is an useful tool to assess teamwork of the whole surgical team (surgeons, anaesthetists, nurses) in real time and through the surgical procedure (pre-intra-postoperative phases). OTAS consists of the two following parts: a) teamwork-related task checklist to fill by a surgeon, b) teamwork-related behaviours rated by a psychologist/human factors expert. Back translation in Italian language of the eight task checklists and of the rating scales of the five behavioural areas was performed by two Italian surgeons with certified English language knowledge. The OTAS model in Italian language was applied in four surgical procedures : the test-retest reliability was found to be acceptable with K- Pearson index. The internal consistency of behavioural scales appeared sound using Cronbach ?. OTAS is an useful tool to assess the risk factors correlated to patient and team and to detect the vulnerability areas where changes to reduce errors and improve surgical outcomes might be introduced.

Growth factors in the therapy of myelodysplasia: biological aspects.

Growth factors (GF) are reported to play an important role in the therapy of myelodisplastic syndromes (MDS). After in vitro administration a consistent group of MDS may respond to GF but the possibility of differentiation, regulation or expansion of myelodisplastic clones following GF therapy is still a question to be answered as their optimum dose and combinations. To validate if in vivo treatment with GF, may promote the regulation or the recovery of myelopoiesis and/or modify the clonality of the responses, we gave G-CSF after intensive chemotherapy in high risk MDS and acute leukemia evolving from MDS patients. According to our data the use of G-CSF after intensive chemotherapy may improve the CR rate without increase of leukemic transformation. However the answer were clonal and the remission duration remained very short so we suggest to utilize this time to perform other therapeutic strategies such as, when possible, the BMT.

[Carcinoma of the gallbladder. Our experience]. / II carcinoma della colecisti. La nostra esperienza.

A series of 11 patients (3 males and 8 females, mean age 63.4 yrs.) suffering from gallbladder cancer has been reviewed. Authors' purpose in reviewing their experience was to identify factors either in patient characteristics or treatment, that may influence statistic data. Symptoms, signs, laboratory and imaging studies were uniformly unhelpful in determining the diagnosis. Early diagnosis at a stage amenable to surgical excision remains the only therapeutical possibility.

[Intensive therapy in general surgery]. / La terapia intensiva in chirurgia generale.

A good diagnostic protocol as well as a proper preparation to surgery and a careful intensive observation (associated if necessary with an intensive therapy) can lead to a better prognosis in major surgical procedures or routine surgery in poor risk patients. Candidates to ICU are divided in three classes: type A is a stable patient requiring constant monitoring for high probability of complications, type B is still a stable patient who needs an intensive nursing; finally type C is an instable patient who requires a true intensive care. In the surgical department of USL 20/B Figline Valdarno (FI) a postoperative Intensive Care Unit (ICU) has been established in the last three years: a three-bed section with its own staff is located in the surgical department itself. In 37 months 467 operated patients requiring intensive observation or intensive therapy have been admitted.

[Subscapular elastofibroma (elastofibroma dorsi)]. / Elastofibroma sottoscapolare (elastofibroma dorsi).

The Authors describe a case of elastofibroma in its typical location; the most interesting aspect of this lesion is the microscopic appearance. The benignity of this lesion is absolute, from the clinical and microscopic points of view.