[Management of risk of errors in health: which representation for a systemic approach?]. / Gestione del rischio di errori in sanità: quale rappresentazione per un approccio di sistema?

The management of the risk of error in Health currently configures as an institutionalized multi/hetero-professional and "complex" activity. This implicates the need to establish rules that codify the modalities of interaction among the actors, as well as rules of communication, which, defining in a clear and univocal way the terminology used, allow the different actors to understand themselves. The representation of these rules implies a systemic and global conceptual approach in which the attention is moved from "the physician's performance" to the "performance in Health": the whole System must be structured and employed in order to pretend towards a continuous improvement of Quality and Safety.

Respiratory failure due to upper airway obstruction in children: use of the helmet as bridge interface.

Upper airway obstruction (UAO) can cause severe respiratory distress in young children by increasing inspiratory muscle load and decreasing alveolar ventilation, ultimately resulting in hypercapnia and hypoxemia which have long term negative cardiovascular effects. Although non-invasive continuous positive airway pressure (CPAP) improves gas exchange in these patients, use of conventional interfaces (nasal mask, nasal pillow and facial mask) may cause significant discomfort and lead to CPAP intolerance. We report five cases of children affected by UAO who experienced CPAP intolerance via application of conventional interfaces. Alternatively, we acutely applied helmet-CPAP which resulted in improved breathing pattern and gas exchange. Thereafter, patients received training with respect to a nasal CPAP interface, allowing successful long term treatment. In conclusion, these five clinical cases demonstrate that helmet-CPAP can be used acutely in children with UAO if compliance to conventional modalities is problematic, allowing for sufficient time to achieve compliance to nasal-CPAP.

Non-invasive positive pressure ventilation in children.

Non-invasive positive pressure ventilation is increasingly used in children both in acute and in chronic setting. Clinical data supporting safety, efficacy and limitations in children are growing. Technical problems related to the ventilators performance and interfaces selection have not been fully resolved, especially for younger children. Non-invasive ventilation can be applied at home. Its use at home requires appropriate diagnostic procedures, accurate titration of the ventilators, cooperative and educated families and careful, well-organized follow-up programs.