Understanding failings in patient safety: lessons from the case of surgeon Ian Paterson.

While rare, incidents of inappropriate and/or unnecessary surgery do occur, so effective surveillance of surgical practice is required to ensure patient safety. This article explores the case of Ian Paterson, a consultant surgeon who was sentenced to 20 years in prison in 2017 for wounding with intent and unlawful wounding, primarily by undertaking inappropriate or unnecessary mastectomies. The article details the main points of the Paterson case, with reference to the subsequent government-commissioned inquiry and its recommendations. It also outlines various strategies for enhancing patient safety, including applying human factors theory, improving auditing, and rationalising NHS and private healthcare. The author concludes that nurses have a crucial role in the surveillance of surgical practice and that combined reporting of surgeons' practice across NHS and private healthcare organisations is required.

Historia de la seguridad del paciente. Hitos principales, desde los albores de la civilización hasta los primeros retos globales y el estudio IBEAS / History of patient's Safety. From the dawn of civilization to the WHO Global Patient Safety Challenges and IBEAS study

Se realiza una breve historia de la seguridad del paciente en la atención médica, desde los albores de las civilizaciones hasta los primeros retos Globales de la OMS y el Estudio IBEAS. (AU)

A brief history of patient safety is made in the medical attention, from the dawn of civilizations up to the first Global challenges of the WHO and the IBEAS Study. (AU)

An historical overview over Pharmacovigilance.

Pharmacovigilance started about 170 years ago, although it was not yet named as such at that time. It is structured activity in the professional health field, with important social and commercial implications aimed at monitoring the risk/benefit ratio of drugs, improving patient's safety and the quality of life. In this commentary we report the milestones of pharmacovigilance up to the present day, in order to understand all the steps that have characterized the historical evolution; from the first reports, which were essentially letters or warnings sent by clinicians to publishers of important and famous scientific journals, up to today's modern and ultra-structured electronic registries. The historical phases also help us to understand why pharmacovigilance helped us to achieve such important results for man's health and for pharmacology itself, and to identify the challenges that await Pharmacovigilance in future years.

Frozen in Time: A History of the Synthesis of Nitrous Oxide and How the Process Remained Unchanged for Over 2 Centuries.

Three major factors have contributed to the unrivaled popularity of nitrous oxide (N2O) among anesthetists in the 20th century and beyond: its impressive safety profile, its affordability, and its rapid induction and emergence times. These 3 characteristics of N2O have been discussed and written about extensively throughout the medical literature. Nonetheless, the characteristic that contributed most to N2O's initial discovery-the elegance and simplicity of its synthesis-has received substantially less attention. Although N2O was first used as an anesthetic in Hartford, CT, in 1844, it had been identified and synthesized as a distinct gas in the late 18th century. In this article, we track the developments in the recognition and early synthesis of N2O, highlight the major players credited with its discovery, and examine its evolution from the late 1700s to today. The discovery and assimilation of N2O into common medical practice, alongside ether and chloroform, heralded a new paradigm in surgical medicine-one that no longer viewed pain as a fundamental component of surgical medicine. Its continued usage in modern medicine speaks to the brilliance and skill of the chemists and scientists involved in its initial discovery.

Viral safety of coagulation factor concentrates: memoirs from an insider.

The purpose of this essay is to recall the actions taken globally to improve the viral safety of coagulation factor concentrates, mainly in the years 1985-1990, at a time of confusing and often contradictory information on bloodborne viral infections in multitransfused patients with hemophilia (PWHs). I shall first recall the problem of the transmission and control of the hepatitis viruses, and then that of HIV: not only for temporal reasons, but also because understanding the progress of knowledge on hepatitis and the poor success of the early measures taken to tackle this problem in PWHs is essential to understand how the problem of HIV transmission was ultimately dealt with successfully.

An Evolving Story of Translational Research: A Decade after the Jacobson Promising Investigator Award.

THE THIRD JOAN L AND JULIUS H JACOBSON PROMISING INVESTIGATOR AWARDEE, MARK PUDER, MD, PHD, FACS: In 2005, the Surgical Research Committee (SRC) of the American College of Surgeons was tasked with selecting the recipient of a newly established award, "The Joan L and Julius H Jacobson Promising Investigator Award." According to the Jacobsons, the award, funded by Dr Jacobson, should be given at least once every 2 years to a surgeon investigator at "the tipping point," who can demonstrate that his or her research shows the promise of leading to a significant contribution to the practice of surgery and patient safety. Every year, the SRC receives many excellent nominations and has the difficult task of selecting 1 awardee. The first awardee was Michael Longaker, MD, FACS, who, 10 years later, reflected on the award and the impact it had on his career.1 This year, Mark Puder, MD, PhD FACS, the third Jacobson awardee, reflects on his 10-year journey after receiving the award. Dr Puder is now a national and international figure in the field of intestinal failure-associated liver disease and has studied the effect of intravenous lipid emulsions on the etiology and treatment of a once fatal disease in children. Kamal MF Itani, MD, FACS and Brian S Zuckerbraun, MD, FACS, on behalf of the Research Committee of the American College of Surgeons.

Evolución histórica de la seguridad del paciente en España / No disponible

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Análisis de los eventos adversos en el área de rehabilitación oral de la Facultad de Odontología de la Ponticia Universidad Javeriana Bogotá / Analysis of Adverse Events in the Oral Rehabilitation Area at the Ponticia Universidad Javeriana Dentistry School in Bogotá

Antecedentes: Uno de los mecanismos para garantizar la calidad de la atención en salud es el análisis de eventos adversos en los tratamientos. El área de la rehabilitación oral es una de las más propensas, dada la complejidad de sus procedimientos. Objetivo: Analizar los eventos adversos que se presentaron en la clínica del posgrado de rehabilitación oral de la Facultad de Odontología de la Pontificia Universidad Javcriana de Bogotá durante 2013. Métodos: De 595 historias clínicas correspondientes a todos los pacientes que finalizaron su tratamiento en 2013. 590 cumplieron con el requisito de estar firmadas por el paciente y por el profesor. A partir de las historias que contenían algún reporte de evento adverso, se registraron los datos demográficos de los pacientes, los tipos de eventos adversos reportados, las posibles causas que su ocurrencia y si eran o no prevenibles. Resultados: En 36 (6,1 %) de las historias clínicas analizadas se encontró algún reporte de evento adverso. El evento más frecuente fue la perdida de la restauración (42 %). La causa más frecuente fue la fractura completa de la restauración (19 %). El 58 % se consideró evento adverso prevenible. En el 61,1 % de los casos fueron prótesis fijas dcntorrctcnidas. Conclusiones: La frecuencia de eventos adversos reportada en las historias clínicas de pacientes atendidos en el área de rehabilitación es baja. Teniendo en cuenta de condición de prevenible de estos casos, es importante registrarlos y analizarlos para asegurar la calidad en la atención de los pacientes.

Background: One of the mechanisms that ensures the health care quality is the analysis of adverse events in the treatment. The oral rehabilitation area is among the more likely because of the complex procedures involved. Objective: To analyze the adverse events that occurred in the clinic of the oral rehabilitation graduate program at the Pontificia Universidad Javeriana Dentistry School in Bogotá during 201 "i.Methods: Out of 595 medical records including all the patients who completed their treatment in 2013. 590 fulfilled the requirement of being signed both by the patient and the teacher. Based on the medical records that reported any kind of adverse event, the patient information regarding demographic data, type of reported adverse event, potential causes for their occurrence, and whether they were preventable was gathered. Results: In 36 (6.1%) of the examined medical records, at least one report of adverse event was found. The most frequently found event was the restoration loss (42%). The most frequently found cause was the full fracture of the restoration (19%). Fifty-eight (58 %) of the adverse events were preventable. Sixty-one (61.1%) of the eases were retained fixed dental prosthcscs. Conclusions: Ihc frequency of adverse events reported in the medical records of patients treated in the rehabilitation area is low. Considering that the eases arc preventable, it is important to record and examine these eases in order to ensure the health care quality for the patients.

Building a Culture of Safety in Ophthalmology.

Patient safety focused on a reduction in both procedural and diagnostic error is the number one concern of the United States healthcare system in the 21st century. The American Board of Ophthalmology has a longstanding interest in patient safety, and in 2015, teamed with the American Academy of Ophthalmology to convene all ophthalmology subspecialties and other prominent national organizations to address patient safety in ophthalmology. This article reviews the topic and highlights concerns for ophthalmologists.

European Network for Patient Safety and Quality of Care: PaSQ / La red de la Unión Europea para la Seguridad del Paciente y la Calidad Asistencial: PasQ

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Primum non nocere, o como trabajar con seguridad para el paciente / Primum Non Nocere or How to Create a Culture of Patient Safety

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