[Patient safety and quality of care]. / Seguridad del paciente y calidad asistencial.

Adverse effects related to health care are common and partly avoidable. We need to identify how and why adverse events occur and how system defects may contribute to their occurrence. Systems and processes can be designed to help prevent errors and decrease harm that occurs when they are not intercepted. Tactics to reduce errors and mitigate their adverse effects include reducing complexity and optimizing information processing. Implementation of information technology may offer great promise but the most important is to make an effort to promote a culture of safety.

Treatment of malignant melanoma.

OBJECTIVE: To review the current treatments for cutaneous melanoma and discuss treatment approaches for each patient population. DATA SOURCES: MEDLINE and IOWA database search from January 1990 to December 1998. DATA EXTRACTION: Clinical trials and review articles were selected and classified to answer questions considered of clinical relevance. RESULTS: Patients with stage I, II, and III melanoma should undergo excision after biopsy. In patients with stage IV melanoma, surgical excision of metastatic melanoma is not considered curative but can provide palliation and improve quality of life. Therapeutic lymph node dissection should be performed in patients with melanoma in stages III and IV once pathologic confirmation is obtained. Patients at high risk for recurrence or metastasis may also be considered for elective node dissection. Adjuvant therapy after surgery excision is not a standard of care in patients with stage I and IIa melanoma. In patients with stage IIb and III melanoma, the best results have been obtained with high doses of interferon alfa-2b, although toxicity is of concern. Isolated limb perfusion with melphalan adjuvant to surgery has demonstrated clinically significant benefit in patients with locally recurrent melanoma and in-transit metastases. Studies comparing efficacy and quality of life with this technique or with high doses of interferon alfa-2b are needed. The technique cannot be recommended for high-risk primary melanoma of an extremity with no clinical evidence of metastatic disease. CONCLUSIONS: To date, dacarbazine still appears to be the treatment of first choice in metastatic melanoma, outside of a clinical trial. The combination of chemotherapy with interferon alfa-2b or interferon alfa-2a enhances toxicity without a significant survival advantage. Aldesleukin may be an alternative in selected patients when other treatments have failed, but the higher toxicity and cost must be considered.