Your browser doesn't support javascript.
Mostrar: 20 | 50 | 100
Resultados 1 - 20 de 94
Filtrar
2.
BMJ ; 366: l4185, 2019 07 17.
Artigo em Inglês | MEDLINE | ID: mdl-31315828

RESUMO

OBJECTIVE: To systematically quantify the prevalence, severity, and nature of preventable patient harm across a range of medical settings globally. DESIGN: Systematic review and meta-analysis. DATA SOURCES: Medline, PubMed, PsycINFO, Cinahl and Embase, WHOLIS, Google Scholar, and SIGLE from January 2000 to January 2019. The reference lists of eligible studies and other relevant systematic reviews were also searched. REVIEW METHODS: Observational studies reporting preventable patient harm in medical care. The core outcomes were the prevalence, severity, and types of preventable patient harm reported as percentages and their 95% confidence intervals. Data extraction and critical appraisal were undertaken by two reviewers working independently. Random effects meta-analysis was employed followed by univariable and multivariable meta regression. Heterogeneity was quantified by using the I2 statistic, and publication bias was evaluated. RESULTS: Of the 7313 records identified, 70 studies involving 337 025 patients were included in the meta-analysis. The pooled prevalence for preventable patient harm was 6% (95% confidence interval 5% to 7%). A pooled proportion of 12% (9% to 15%) of preventable patient harm was severe or led to death. Incidents related to drugs (25%, 95% confidence interval 16% to 34%) and other treatments (24%, 21% to 30%) accounted for the largest proportion of preventable patient harm. Compared with general hospitals (where most evidence originated), preventable patient harm was more prevalent in advanced specialties (intensive care or surgery; regression coefficient b=0.07, 95% confidence interval 0.04 to 0.10). CONCLUSIONS: Around one in 20 patients are exposed to preventable harm in medical care. Although a focus on preventable patient harm has been encouraged by the international patient safety policy agenda, there are limited quality improvement practices specifically targeting incidents of preventable patient harm rather than overall patient harm (preventable and non-preventable). Developing and implementing evidence-based mitigation strategies specifically targeting preventable patient harm could lead to major service quality improvements in medical care which could also be more cost effective.


Assuntos
Prática Clínica Baseada em Evidências/métodos , Dano ao Paciente/prevenção & controle , Dano ao Paciente/tendências , Estudos Transversais , Prática Clínica Baseada em Evidências/normas , Humanos , Estudos Observacionais como Assunto , Dano ao Paciente/mortalidade , Segurança do Paciente , Prevalência , Melhoria de Qualidade , Estudos Retrospectivos , Índice de Gravidade de Doença
3.
Gac. sanit. (Barc., Ed. impr.) ; 33(3): 242-248, mayo-jun. 2019. tab, graf
Artigo em Espanhol | IBECS | ID: ibc-183743

RESUMO

Objetivo: Valorar diferencias entre necesidad e implementación de prácticas seguras recomendadas para la seguridad del paciente y utilidad del uso de señales de tráfico para promover su implementación. Método: El estudio constó de dos fases: 1) revisión de recomendaciones sobre prácticas seguras de diferentes organizaciones y 2) encuesta a una muestra de oportunidad de profesionales del ámbito asistencial, organizativo y académico de la seguridad del paciente de España y Latinoamérica para evaluar necesidad y la implementación percibida de las prácticas seguras y la utilidad de las señales para tal fin. Resultados: Se recibieron 365 cuestionarios. Todas las prácticas seguras identificadas fueron valoradas como necesarias (media y límite inferior del intervalo de confianza por encima de 3 sobre 5 puntos). Sin embargo, la implementación se valoró como insuficiente en seis de ellas: escritura ilegible, conciliación de medicación, estandarización de comunicación, sistemas de alerta rápida, aplicación de procedimientos por profesionales o equipos entrenados, y cumplimiento de voluntades del paciente al final de la vida. Mejorar cumplimiento de la higiene de manos, aplicación de precauciones de barrera, asegurar la identificación correcta de los pacientes y utilizar listados de verificación fueron las cuatro prácticas en las que más del 75% de los encuestados encuentran mayor grado de consenso sobre la utilidad de las señales de tráfico para mejorar su implementación. Conclusiones: Las diferencias entre necesidad percibida e implementación real de las prácticas seguras consideradas indican áreas de mejora. El lenguaje común de las señales de tráfico es un instrumento sencillo para mejorar su cumplimiento


Objective: To evaluate differences between the need and degree of implementation of safe practices recommended for patient safety and to check the usefulness of traffic sign iconicity to promote their implementation. Method: The study was developed in two stages: 1) review of safe practices recommended by different organizations and 2) a survey to assess the perceptions for the need and implementation of them and the usefulness of signs to improve their implementation. The sample consisted of professionals from Spain and Latin America working in healthcare settings and in the academic field related to patient safety. Results: 365 questionnaires were collected. All safe practices included were considered necessary (mean and lower limit of confidence interval over 3 out of 5 points). However, in six of the patient safety practices evaluated the implementation was considered insufficient: illegible handwriting, medication reconciliation, standardization of communication systems, early warning systems, procedures performed or equipment used only by trained people, and compliance with patient preferences at the end of life. Improve compliance of with hand hygiene and barrier precautions to prevent infections, ensure the correct identification of patients and the use of checklists are the four practices in which more than 75% of respondents found a high degree of consensus on the usefulness of traffic sings to broaden their use. Conclusion: The differences between perceived need and actual implementation in some safe practices indicate areas for improvement in patient safety. With this aim, the common language and the iconicity of traffic signs could constitute a simple instrument to improve compliance with safe practices for patient safety


Assuntos
Humanos , Segurança do Paciente/normas , Gestão de Riscos/métodos , Dano ao Paciente/prevenção & controle , Doença Iatrogênica/prevenção & controle , Efeitos Colaterais e Reações Adversas Relacionados a Medicamentos/prevenção & controle , Determinação de Necessidades de Cuidados de Saúde/organização & administração , Guias de Prática Clínica como Assunto
4.
Prensa méd. argent ; 105(2): 53-61, apr 2019. tab
Artigo em Espanhol | LILACS, BINACIS | ID: biblio-1025650

RESUMO

La cirugía de control de daños (CCD), surge con el afán de mejorar los pobres resultados obtenidos con el abordaje quirúrgico tradicional en traumatismos abdominales graves y exanguinantes en pacientes críticos con escasa reserva fisiológica. Se define con una "cirugía por etapas", con un primer tiempo quirúrgico corto para controlar el sangrado y la contaminación con cierre temporario abdominal, seguido de un período de reanimación en unidad de cuidados intensivos y, finalmente, de reparación definitiva de las lesiones. Se revisaron las histrias clínicas de 41 pacientes sometidos a éste tipo de cirugía en el período comprendido entre marzo de 2011 y octubre de 2017 en el Hospital Municipal de Urgencias de la ciudad de Córdoba, 29 hombres y 12 mujeres, en cuanto al mecanismo lesional 23 casos fueron por trauma cerrado y 18 penetrantes. La edad promedio fue de 30 años, 28 pacientes presentaron lesiones asociadas, siendo las más frecuentes las torácicas en 14 pacientes y la mortalidad global de la serie del 41% (17 pacientes). El grupo etario involucrado, la distribución por sexo, y la mortalidad de nuestra serie no difiere de la bibliografía consultada


Damaage control surgery (CCD) arises with the aim of imporving the poor results obtained with the traditional surgical approach in severe and exanguinating abdominal trauma in critically ill patients with scarce physiological reserve. It is defined as a "step surgery", with a short surgical first time to control bleeding and contamination with temporary abdominal closure, followed by a period of resuscitation in the intensive care unit and, finally, definitive repair of the injuries. We revierwed the medical rcords of 41 patients undergoing this type of surgery in the period between arch 2011 and October 2017 at the Municipal Emergenci Hospital of the city of Córdoba, 29 men and 12 women, regarding the mechanism of injury 23 cases were due to closed trauma and 18 penetrating. The average age was 30 years, 28 patients had associated injuries, the most frequent being thoracic in 14 patients and the overall mortality of the series of 41% (17 patients). The age group involved, the distributin by sex, and the mortality of our series does not differ from the bibliography consulted


Assuntos
Humanos , Masculino , Feminino , Adolescente , Adulto , Pessoa de Meia-Idade , Índices de Gravidade do Trauma , Indicadores de Morbimortalidade , Redução do Dano , Hipertensão Intra-Abdominal/prevenção & controle , Dano ao Paciente/prevenção & controle , Traumatismos Abdominais/cirurgia
5.
Enferm. nefrol ; 22(1): 27-33, ene.-mar. 2019. tab, graf
Artigo em Espanhol | IBECS | ID: ibc-183591

RESUMO

Los pacientes en hemodiálisis son una población susceptible de padecer eventos adversos por fallos en el proceso asistencial. Objetivo: Evaluar la eficacia de las medidas correctoras en un plan de seguridad del paciente en hemodiálisis para disminuir los eventos adversos. Material y Método: Estudio descriptivo y retrospectivo del registro de hemodiálisis de una unidad hospitalaria. Como método de evaluación se utilizó la metodología propia de nuestro centro (MIDEA) basado en el método Global Trigger Tools. Se revisaron todas las sesiones de hemodiálisis de marzo, mayo y julio de 2016: 2.080 sesiones; y los mismos meses en 2017: 1953 sesiones. Después del análisis de 2016, se implantaron las siguientes medidas correctoras: revisión del procedimiento de anticoagulación del circuito extracorpóreo, actualización del manejo de los accesos vasculares y actualización del procedimiento ante hipotensiones. Resultados: En el año 2016, se revisaron las gráficas de 208 pacientes. Se detectaron 255 eventos adversos (11,8% de las sesiones), siendo los más frecuentes: 85 hipotensiones, 74 coagulaciones del circuito sanguíneo, 31 problemas del acceso vascular y 65 otros eventos adversos. En el año 2017, se revisaron las gráficas de 258 pacientes. Se detectaron 155 eventos adversos (7,9% de las sesiones), siendo los más frecuentes: 60 hipotensiones, 36 coagulaciones del circuito, 30 problemas del acceso vascular y 29 otros eventos adversos. Conclusiones: Los eventos adversos disminuyeron un 39,2% en 2017, y aunque siguen siendo las hipotensiones, coagulaciones del circuito sanguíneo y los problemas derivados del acceso vascular los más frecuentes, pensamos que las medidas correctoras están siendo eficaces


Patients on hemodialysis (HD) are a population susceptible to suffering adverse events (AD) due to failures in the healthcare process. Objective: To evaluate the efficacy of corrective measures in a HD patient safety plan to reduce AD. Material and Method: Descriptive and retrospective study of the HD records of a hospital unit. As an evaluation method, we used the methodology of our center (MIDEA) based on the Global Trigger Tools method. All the HD sessions of March, May and July 2016 were reviewed: 2,080 sessions; and the same months in 2017: 1953 sessions. After the 2016 analysis, the following corrective measures were implemented: revision of the anticoagulation procedure of the extracorporeal circuit, updating of the vascular access management and updating of the procedure before hypotension. Results: In 2016, the clinical records of 208 patients were reviewed. 255 EA were detected (11.8% of the sessions). The most frequent AEs were: 85 hypotension, 74 blood circuit coagulations, 31 vascular access problems and 65 other AD. In 2017, the clinical records of 258 patients were reviewed. 155 AE were detected (in 7.9% of the sessions). The most frequent AEs were: 60 hypotension, 36 circuit coagulations, 30 vascular access problems and 29 other AE. Conclusions: Adverse events decreased by 39.2% in 2017, and although hypotension, blood circuit coagulation and vascular access problems are the most frequent, we consider that corrective measures are being effective


Assuntos
Humanos , Diagnóstico de Enfermagem/métodos , Diálise Renal/efeitos adversos , Unidades Hospitalares de Hemodiálise/normas , Dano ao Paciente/prevenção & controle , Doença Iatrogênica/prevenção & controle , Insuficiência Renal Crônica/terapia , Avaliação de Resultado de Ações Preventivas , Segurança do Paciente/normas , Estudos Retrospectivos
6.
Enferm. nefrol ; 22(1): 42-50, ene.-mar. 2019. tab, graf
Artigo em Espanhol | IBECS | ID: ibc-183593

RESUMO

Objetivo: Determinar los eventos adversos más prevalentes y los factores asociados a su desarrollo en el paciente que se somete a hemodiálisis en el estado de Guerrero, México. Material y Método: Estudio observacional, longitudinal, retrospectivo en 157 pacientes en hemodiálisis afiliados al Instituto Mexicano del Seguro Social en Guerrero, atendidos en 5 unidades privadas y 2 públicas. Se recolectaron variables socio-demográficas, mediciones de laboratorio, evolución de la enfermedad, complicaciones propias de la enfermedad y del tratamiento dialítico. Resultados: Los eventos adversos se presentaron en el 73% de la población estudiada, la principal causa etiológica fue Diabetes mellitus tipo 2 (DM2) e hipertensión arterial. Los eventos adversos más frecuentes fueron: hipotensión (35,5%) infección de angioacceso (24%), cefalea (22,3%), crisis hipertensiva (14,5%), mareos (9,9%), escalofríos (9,9%), y trombosis de fístula arteriovenosa (9,9%). Los factores que se asociaron a su desarrollo fueron: pacientes mayores de 65 años, (OR=6,859IC 95%;1,55-30,35), ser obeso, (OR=1,70, IC95%:1,60-4,81), e hipoalbuminemia (OR=0,251, IC 95%: 0,160-0,593). Conclusión: Los pacientes mayores de 65 años, obesos, con hipertensión diastólica e hipoalbuminemia tienen mayor probabilidad de desarrollar eventos adversos durante el periodo de hemodiálisis


Objective: To determine the most prevalent adverse events and the risk factors associated in the patient undergoing hemodialysis in the state of Guerrero, Mexico. Material and Method: Observational, longitudinal, retrospective study in 157 hemodialysis patients affiliated to the Mexican Institute of Social Security in Guerrero, assisted in 5 private and 2 public units. Socio-demographic variables, laboratory measurements, evolution of the disease, complications of the disease and dialysis treatment were collected. Results: Adverse events occurred in 73% of the studied population, the main etiological cause was Diabetes mellitus type 2 (DM2) and arterial hypertension. The most frequent adverse events were: hypotension (35.5%) angioaccess infection (24.0%), headache (22.3%), hypertensive crisis (14.5%), dizziness (9.9%), chills (9.9%), and thrombosis of arteriovenous fistula (9.9%). The associated risk factors: patients over 65, (OR=6.859, 95% CI:1.55-30.35) being obese, (OR=1.70, 95% CI: 1.60-4.81), and hypoalbuminemia (OR=0.251, 95% CI:0.160-0.593). Conclusion: Patients over 65, obese, with diastolic hypertension and hypoalbuminemia are more likely to develop adverse events during the hemodialysis


Assuntos
Humanos , Masculino , Feminino , Pessoa de Meia-Idade , Idoso , Diagnóstico de Enfermagem/métodos , Diálise Renal/efeitos adversos , Unidades Hospitalares de Hemodiálise/normas , Dano ao Paciente/prevenção & controle , Doença Iatrogênica/prevenção & controle , Insuficiência Renal Crônica/terapia , Segurança do Paciente/normas , Estudos Retrospectivos , México/epidemiologia , Fatores de Risco , Obesidade/complicações , Hipertensão/complicações
7.
J Pediatr Surg ; 54(9): 1872-1877, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-30765152

RESUMO

INTRODUCTION: Peer-review endeavors represent the continual learning environment critical for a culture of patient safety. Morbidity and mortality (M&M) conferences are designed to review adverse events to prevent future similar events. The extent to which pediatric surgeons participate in M&M, and believe M&M improves patient safety, is unknown. METHODS: A cross-sectional survey of the American Pediatric Surgical Association membership was conducted to evaluate participation in and perception of M&M conferences. Closed and open-ended questions were provided to gauge participation and perceptions of M&M effectiveness. Standard frequency analyses and tests of associations between M&M program attributes and surgeons' perceptions of effectiveness were performed. RESULTS: The response rate was 38% (353/928). Most surgeons (85%) reported that they always participate in M&M, but only 64% believe M&M is effective in changing practice or prevention of future adverse events. Effective M&Ms were more likely to emphasize loop closure, multidisciplinary participation, standardized assessment of events, and connection to quality improvement efforts. CONCLUSIONS: Most pediatric surgeons participate in M&M, but many doubt its effectiveness. We identified attributes of M&M conferences that are perceived to be effective. Further investigation is needed to identify how to optimally utilize peer-review programs to prevent adverse events and improve patient safety. LEVEL OF EVIDENCE: V.


Assuntos
Dano ao Paciente/prevenção & controle , Segurança do Paciente/normas , Pediatras , Cirurgiões , Estudos Transversais , Humanos , Morbidade , Pediatras/organização & administração , Pediatras/estatística & dados numéricos , Melhoria de Qualidade , Cirurgiões/organização & administração , Cirurgiões/estatística & dados numéricos
8.
Pediatrics ; 143(2)2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-30670581

RESUMO

Pediatricians render care in an increasingly complex environment, which results in multiple opportunities to cause unintended harm. National awareness of patient safety risks has grown since the National Academy of Medicine (formerly the Institute of Medicine) published its report "To Err Is Human: Building a Safer Health System" in 1999. Patients and society as a whole continue to challenge health care providers to examine their practices and implement safety solutions. The depth and breadth of harm incurred by the practice of medicine is still being defined as reports continue to reveal a variety of avoidable errors, from those that involve specific high-risk medications to those that are more generalizable, such as patient misidentification and diagnostic error. Pediatric health care providers in all practice environments benefit from having a working knowledge of patient safety language. Pediatric providers should serve as advocates for best practices and policies with the goal of attending to risks that are unique to children, identifying and supporting a culture of safety, and leading efforts to eliminate avoidable harm in any setting in which medical care is rendered to children. In this Policy Statement, we provide an update to the 2011 Policy Statement "Principles of Pediatric Patient Safety: Reducing Harm Due to Medical Care."


Assuntos
Redução do Dano , Erros Médicos/prevenção & controle , Dano ao Paciente/prevenção & controle , Gestão da Segurança/tendências , Criança , Humanos , Erros Médicos/tendências , Dano ao Paciente/tendências , Segurança do Paciente/normas , Gestão da Segurança/métodos , Gestão da Segurança/normas
10.
Rev. Rol enferm ; 41(9): 606-615, sept. 2018. ilus
Artigo em Espanhol | IBECS | ID: ibc-179701

RESUMO

Objetivos: Describir el concepto, origen, medida y estrategias organizacionales para fomentar la cultura de seguridad del paciente. Justificar el liderazgo enfermero en el marco de la seguridad del paciente en el ámbito clínico. Método: Análisis conceptual a partir de la revisión crítica de la literatura sobre el tema. Resultados: Las cuatro líneas estratégicas para la realización de un plan de calidad y seguridad son la creación de un comité de seguridad del paciente, la implementación de un sistema de declaración y gestión de los incidentes, la información y formación a los profesionales y, por último, el empoderamiento del paciente. La medición de la cultura de seguridad permite analizar los puntos fuertes y los de mejora a nivel institucional. Según varios estudios, la dotación de personal y el soporte de la dirección destacan como aspectos con mayor margen de mejora para un aumento de la cultura de seguridad. Conclusiones: Tras enmarcar la importancia y a su vez la dificultad de garantizar la seguridad del paciente en las organizaciones sanitarias y el compromiso de las enfermeras, se concluye la necesidad de la implicación de todas las disciplinas asistenciales y no asistenciales, de los políticos, de los gestores y de los propios pacientes para poder lograr unos hospitales más seguros en la atención a todos los ciudadanos


Aims: To describe the concept, background, measures and organizational strategies to promote a culture of patient safety; to justify nursing leadership in the context of patient safety in the clinical setting. Method: A conceptual analysis based on critical review of literature on the subject. Results: The four strategic lines required to carry out a safety and quality plan are the creation of a patient-safety committee, implementation of an incident reporting and management system, provision of information and training for professionals and, finally, patient empowerment. Assessment of the safety culture allows analysis of strengths along with facets that can be improved at an institutional level. According to various studies, staffing and management support stand out as aspects with the greatest margin for improvement in enhancing the safety culture. Conclusions: Subsequent to framing the importance, and consequent difficulty, of ensuring patient safety in health organisations and the commitment of nurses, it can be concluded that here is a need for all care disciplines to be involved, non-caregivers, politicians, managers and the patients themselves, to achieve safer hospitals for the care of all citizens


Assuntos
Humanos , Cultura Organizacional , Gestão da Segurança/organização & administração , Cuidados de Enfermagem/organização & administração , Qualidade da Assistência à Saúde/organização & administração , Liderança , Segurança do Paciente/estatística & dados numéricos , Dano ao Paciente/prevenção & controle , Indicadores de Qualidade em Assistência à Saúde , Hospitalização/estatística & dados numéricos
11.
Prog Transplant ; 28(3): 271-277, 2018 09.
Artigo em Inglês | MEDLINE | ID: mdl-30012054

RESUMO

BACKGROUND: In 2012, the Health Resources and Services Administration and the United Network for Organ Sharing launched the "Electronic Tracking and Transportation" (ETT) project, in response to "labeling and packaging issues" being a frequently reported safety incident. This article describes an improvement project conducted as part of this United Network for Organ Sharing project. METHODS: An interdisciplinary team conducted a Process Failure Modes and Effects Analysis, laboratory simulations of organ labeling during procurement, and a heuristic evaluation of a label software application to inform the design of TransNet, a system that uses barcode technology at the point of organ recovery. A total of 42 clinicians and staff from 10 organ procurement organizations and 2 transplant centers in the United States participated. Processes Addressed: Key features of the redesigned labeling system include independent, double entry of label information into the software application, a machine-readable barcode on each organ's label, and a handheld printer for at "point of use" label printing. OUTCOMES: The new labeling system, TransNet, has become mandatory since June 2017. A survey conducted on early adopters (N = 11), after 1 year of use, indicates the process is safer and more efficient. IMPLICATIONS FOR PRACTICE: The findings from this study suggest that the application of quality planning methods, common in other industries, when redesigning a health-care process, are valuable and revelatory and should be adopted more extensively. Future evaluation of TransNet effectiveness to reduce safety incidents is critical.


Assuntos
Guias como Assunto , Dano ao Paciente/prevenção & controle , Rotulagem de Produtos/normas , Gestão da Segurança/normas , Obtenção de Tecidos e Órgãos/normas , Transplantes/normas , Humanos , Estados Unidos
13.
J Infus Nurs ; 36(1): 58-65, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-29293199

RESUMO

A scoping review of the literature examined strategies to prevent infusion-associated medication errors. Twenty articles were appraised and revealed studies using different research designs and types of literature reviews. Most were rated low quality. Observations in clinical agencies and laboratory settings were sites of some investigations. The work environment-including staffing, health care providers' education and supervision, standardizing equipment, protocols that supported medication decision-making and administration processes, medication lists, computerized devices, and cognitive aids-were addressed as strategies. The array of studies points to aspects of the complexity of the administration process for infusion-associated medications.


Assuntos
Administração Intravenosa , Infusões Intravenosas/métodos , Erros de Medicação/prevenção & controle , Dano ao Paciente/prevenção & controle , Humanos
14.
Nurs Inq ; 25(2): e12225, 2018 04.
Artigo em Inglês | MEDLINE | ID: mdl-28980365

RESUMO

In recent decades, debate on the quality and safety of healthcare has been dominated by a measure and manage administrative rationality. More recently, this rationality has been overlaid by ideas from human factors, ergonomics and systems engineering. Little critical attention has been given in the nursing literature to how risk of harm is understood and actioned, or how patients can be subjectified and marginalised through these discourses. The problem of assuring safety for particular patient groups, and the dominance of technical forms of rationality, has seen the word 'unavoidable' used in connection with intractable forms of patient harm. Employing pressure injury policy as an exemplar, and critically reviewing notions of risk and unavoidable harm, we problematise the concept of unavoidable patient harm, highlighting how this dominant safety rationality risks perverse and taken-for-granted assumptions about patients, care processes and the nature of risk and harm. In this orthodoxy, those who specify or measure risk are positioned as having more insight into the nature of risk, compared to those who simply experience risk. Driven almost exclusively as a technical and administrative pursuit, the patient safety agenda risks decentring the focus from patients and patient care.


Assuntos
Erros Médicos/classificação , Indicadores de Qualidade em Assistência à Saúde/tendências , Gestão de Riscos/normas , Disparidades em Assistência à Saúde/classificação , Humanos , Dano ao Paciente/classificação , Dano ao Paciente/prevenção & controle , Gestão de Riscos/métodos , Populações Vulneráveis
15.
Rev Esp Anestesiol Reanim ; 65(4): e5-e8, 2018 Apr.
Artigo em Inglês, Espanhol | MEDLINE | ID: mdl-29037430

RESUMO

We present a case reported on the SENSAR database. A patient with a spinal infusion pump was admitted for reservoir refill. On administration of 22ml of 0.75% bupivacaine the patient suffered a total spinal block with widespread loss strength and respiratory arrest. The patient required emergency orotracheal intubation, mechanical ventilation and admission to ICU, where extubation was achieved within two hours without incidences. At a later stage it was stated that the local anaesthetic had been administered via the access port for bolus or contrast administration instead of via the access to the reservoir. Analysis of the incident showed up latent factors related to absence lack of personnel training and internal protocols. The following measures were taken: pain unit meeting, alert sent to SENSAR bulletin and training request for members of the service.


Assuntos
Anestésicos Locais/efeitos adversos , Bupivacaína/efeitos adversos , Falha de Equipamento , Bombas de Infusão Implantáveis , Infusão Espinal/instrumentação , Erros de Medicação , Paraplegia/induzido quimicamente , Paralisia Respiratória/induzido quimicamente , Anestésicos Locais/administração & dosagem , Bupivacaína/administração & dosagem , Protocolos Clínicos , Emergências , Humanos , Intubação Intratraqueal , Erros de Medicação/prevenção & controle , Midazolam/uso terapêutico , Morfina/administração & dosagem , Dano ao Paciente/prevenção & controle , Propofol/uso terapêutico , Respiração Artificial , Paralisia Respiratória/tratamento farmacológico , Paralisia Respiratória/terapia , Gestão de Riscos , Succinilcolina/uso terapêutico
16.
Anesth Analg ; 126(5): 1548-1550, 2018 05.
Artigo em Inglês | MEDLINE | ID: mdl-28991108

RESUMO

Massachusetts state agencies received reports of 37 adverse events (AEs) involving cataract surgery from 2011 to 2015. Fifteen were anesthesia related, including 5 wrong eye blocks, 3 cases of hemodynamic instability, 2 retrobulbar hematoma/hemorrhages, and 5 globe perforations resulting in permanent loss of vision. While Massachusetts' reported AEs likely underrepresent the true number of AEs that occur during cataract surgery, they do offer useful signal data to indicate the types of patient harm occurring during these procedures.


Assuntos
Extração de Catarata/efeitos adversos , Catarata/diagnóstico , Catarata/epidemiologia , Dano ao Paciente/efeitos adversos , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/epidemiologia , Humanos , Massachusetts/epidemiologia , Dano ao Paciente/prevenção & controle
17.
Esc. Anna Nery Rev. Enferm ; 22(4): e20170402, 2018. tab, graf
Artigo em Português | LILACS, BDENF - Enfermagem | ID: biblio-953466

RESUMO

Objectives: To analyze the current way medications are prepared and administered in the hospital setting and to apply a method to establish priorities for problems detected. Method: This is an exploratory-descriptive case study. The data were collected through observation and focus groups with 13 participants who were part of a health team in a surgical inpatient unit of a public university hospital. The analysis was based on a lean production framework. Results: A value stream map was constructed of the current way drugs are prepared and administered, identifying the clients in the process and their requirements. Forty-five current problems were identified, based on requirements that were not met with eight being prioritized to improve planning. Conclusion: Having prioritized the problems, the planning and implementation of continuous improvements in the medication process were started in order to reduce errors and improve the quality of services.


Objetivos: Analizar la situación actual de la preparación y administración de medicamentos en el contexto hospitalario y aplicar método para establecer prioridades entre los problemas levantados. Método: Estudio de caso, exploratorio-descriptivo. La recolección de datos se dio por medio de observación y dos Grupos Focales con 13 participantes que integran el equipo de salud de una unidad de internación quirúrgica de un hospital público universitario. El análisis siguió el referencial Lean o producción sobria. Resultados: Se constituyó el Mapa de Flujo de Valor del estado actual de la preparación y administración de medicamento, identificando los clientes del proceso y sus requisitos. Se listaron 45 problemas vigentes, con base en los requisitos no atendidos, con vistas a la planificación de mejoras. Conclusión: En la medida en que se dio prioridad a los problemas, se inició la planificación e implantación de mejoras continuada del proceso de medicación, con vistas a reducir errores y a mejorar la calidad de los servicios.


Objetivos: Analisar a situação atual do preparo e administração de medicamentos no contexto hospitalar e aplicar método para estabelecer prioridades entre os problemas levantados. Método: Estudo de caso, exploratório-descritivo. A coleta de dados deu-se por meio de observação e dois Grupos Focais com 13 participantes que integravam a equipe de saúde de uma unidade de internação cirúrgica de um hospital público universitário. A análise seguiu o referencial Lean ou produção enxuta. Resultados: Construiu-se o Mapa de Fluxo de Valor do estado atual do preparo e administração de medicamento, identificando-se os clientes do processo e seus requisitos. Entre os 45 problemas vigentes levantados, com base nos requisitos não atendidos, oito foram priorizados com vistas ao planejamento de melhorias. Conclusão: Na medida em que os problemas foram priorizados iniciaram-se o planejamento e implantação de melhorias contínuas no processo de medicação, com vistas a reduzir erros e melhorar a qualidade dos serviços.


Assuntos
Humanos , Equipe de Assistência ao Paciente/estatística & dados numéricos , Qualidade da Assistência à Saúde , Dano ao Paciente/prevenção & controle , Erros de Medicação/prevenção & controle , Erros de Medicação/estatística & dados numéricos , Hospitais Universitários
18.
Rev. calid. asist ; 32(6): 335-341, nov.-dic. 2017. ilus, graf, tab
Artigo em Espanhol | IBECS | ID: ibc-169239

RESUMO

Objetivo. Describir un sistema integral de notificación y gestión de incidencias creado por el EAP Guineueta, así como sus principales resultados, después de 18 meses de su implementación. Material y método. A través de un sencillo formulario online, los profesionales comunican cualquier tipo de incidencia, ya categorizada. Cada una de ellas se distribuye a un equipo de mejora que evalúa y realiza las acciones necesarias. Además, en la Comisión de Calidad se analizan inmediatamente las que afectan a la seguridad del paciente y semestralmente las más destacadas o repetitivas. Resultados. Durante los 18 primeros meses de funcionamiento del sistema los profesionales del equipo han comunicado 1.267 incidencias, destacando las informáticas, las de mantenimiento/aparataje técnico asistencial, las de programaciones de agendas y los errores en circuitos y protocolos internos. Ocho se consideraron que afectaban significativamente la seguridad del paciente. Conclusiones. La implementación del sistema descrito se ha consolidado en nuestro equipo, facilitando la detección de problemas, la realización de acciones de mejora e implicando a los profesionales en la mejora de la calidad (AU)


Objective. To describe an integral system of notification and management of incidents, created by the Primary Care Team of Guineueta, as well as the main results after 18 months of implementation. Material and method. Using a simple online form, health professionals notified any type of, already categorised, incident. Each of them were distributed to an improvement team that assessed and performed the necessary actions. In addition, the Quality Committee immediately assessed the ones that affected patient safety, as well as the most relevant or repetitive ones every 6 months. Results. During the first 18 months of operation of the system, the health professionals reported 1,267 incidents, most notably informatics, maintenance/technical assistance, and errors in scheduling, in internal circuits and protocols. Eight of them were considered to significantly affect patient safety. Conclusions. The implementation of the described system has been consolidated into our team, facilitating the detection of problems, the accomplishment of improvement actions and involving the professionals in the improvement of the quality (AU)


Assuntos
Humanos , Dano ao Paciente/prevenção & controle , Gestão da Segurança/organização & administração , Segurança do Paciente/normas , Atenção Primária à Saúde , Gestão de Riscos/organização & administração
19.
Acta pediatr. esp ; 75(11/12): 119-121, nov.-dic. 2017.
Artigo em Espanhol | IBECS | ID: ibc-170219

RESUMO

Introducción: La seguridad del paciente es esencial para garantizar la calidad sistencial. Los incidentes son habituales en la práctica clínica diaria; sin embargo, existen pocos estudios que analicen la incidencia de eventos adversos (EA) en la población pediátrica. Los trigger tools son señales de alerta que permiten sospechar la posibilidad de aparición de EA. El objetivo de este estudio era analizar la sensibilidad de esta herramienta adaptada a un servicio de urgencias pediátricas de un hospital de tercer nivel para la identificación de los EA. Pacientes y métodos: Se seleccionaron 29 triggers aplicables en nuestro medio. En total, se estudiaron 140 pacientes aleatorizados atendidos en el servicio de urgencias entre el 1 de enero y el 31 de julio de 2015. Resultados: Se registraron 48 triggers en 38 de las 140 historias revisadas. En ellas, finalmente se detectó algún EA en 9 historias (una de ellas con 2 triggers). Esto supone la identificación de EA en casi el 21% de las historias clínicas que incluyen triggers. El trigger detectado con más frecuencia, asociado a un mayor porcentaje de EA, fue «reingreso por el mismo motivo en menos de 72 horas tras el alta hospitalaria», seguido de «dosis inadecuada de fármacos». Conclusiones: Los trigger tools no han demostrado rentabilidad para la detección sistemática de EA en nuestro medio. El primer trigger mencionado antes parece tener mayor sensibilidad para detectar potenciales EA. Por ello, sería recomendable la evaluación sistemática de las historias en las que éste aparezca (AU)


Introduction: Patient safety is essential in health system. Incidents are common in daily clinical practice; however, few studies have analyzed the incidence of adverse events (AEs) in the pediatric population. The trigger tools are simple warning signs for suspecting AEs. The aim of this study was to know the sensitivity of this tool adapted to a pediatric emergency department in a tertiary referral hospital. Patients and methodology: 29 suitable triggers were selected. In total, we studied 140 randomized patients seen in the emergency room between 1 January and 31 July 2015. Results: 48 triggers were seen in 38 of the 140 clinical files. AEs were detected in 9 histories (one with 2 triggers), almost 21% of medical records that include triggers. The most frequently detected and associated with a higher percentage of AEs was «readmission for the same reason in less than 72 hours after hospital discharge» followed by «inadequate drug dosage». Conclusions: The trigger tools have not demonstrated profitability for screening of AEs in our hospital. The trigger «readmission for the same reason within 72 hours» seems to be more sensitive to detect potential AEs. Therefore, it would be reasonable to assess the records in which it appears (AU)


Assuntos
Humanos , Gestão da Segurança/métodos , Gestão de Riscos/métodos , Dano ao Paciente/prevenção & controle , Serviço Hospitalar de Emergência/organização & administração , Segurança do Paciente , Indicadores de Qualidade em Assistência à Saúde
20.
Med. paliat ; 24(4): 204-209, oct.-dic. 2017. tab
Artigo em Espanhol | IBECS | ID: ibc-167610

RESUMO

Objetivos: Mejorar la seguridad del paciente es necesario en las unidades de cuidados paliativos donde no hay datos de incidentes y eventos adversos. Se analizaron los tipos de incidentes/eventos adversos, su frecuencia y gravedad en la Unidad de Cuidados Paliativos de un hospital de agudos geriátrico con el objetivo de introducir medidas que pudieran reducir su incidencia. Material y métodos: Estudio retrospectivo de 6 años utilizando un sistema de notificación voluntaria, un sistema de notificación obligatoria para las caídas de los pacientes y la herramienta Global Trigger Tool. Se llevó a cabo en un hospital geriátrico universitario español de 200 camas (27 camas en la Unidad de Cuidados Paliativos). Se incluyeron todos los pacientes ingresados en la Unidad (1.854). La severidad del daño se calculó por el Index of the National Coordinating Council for Medication Error Reporting and Prevention. Resultados: Se identificaron 743 incidentes/eventos adversos, de los cuales 518 (69,7%) eran incidentes (categorías A-D de la clasificación del National Coordinating Council for Medication Error Reporting and Prevention) y 201 eventos adversos (categorías E-I). Los cuidados generales (51,5%) y los errores de medicación (45,2%) fueron los más frecuentes. De estos últimos, los más comunes eran las omisiones de dosis/medicamentos (43,5%). Tanto los antihipertensivos-IECA, antibióticos, antiepilépticos y neurolépticos presentaban tasas de error por encima de la media (5,2), cuando se calcularon los cocientes de incidentes/dispensación. Conclusiones: Este estudio revela un nivel de eventos adversos nada desdeñable dada la conocida falta de sensibilidad de los métodos de detección de eventos adversos, lo que implica la necesidad de desarrollar marcadores de alarma específicos de cuidados paliativos (AU)


Objectives: Improving patient safety is necessary in palliative care units where data on incidents and adverse events are lacking. An analysis was performed on the types of incidents/adverse events, their frequency and severity in the Palliative Care Unit of an Acute Geriatric Hospital with the aim of introducing measures that might lower their incidence. Material and methods: A 6 year retrospective study was conducted using a voluntary reporting system, a compulsory reporting system for patient falls, and the Global Trigger Tool in a Spanish urban geriatric teaching hospital of 200 beds (27 beds in the Palliative Care Unit). All patients (1,854) admitted to the Unit were included. The Index of the National Coordinating Council for Medication Error Reporting and Prevention was used to evaluate severity. Results: A total of 743 incidents/adverse events were identified, of which 518 (69.7%) were incidents (categories A-D of the National Coordinating Council for Medication Error Reporting and Prevention classification), and 201 were adverse events (categories E-I). General care (51.5%) and medication errors (45.2%) were the most frequent. Of the latter, missing doses/drugs were most common (43.5%). Antihypertensives-ACEIs, antibiotics, antiepileptics, and neuroleptics showed mistake rates above the mean (5.2) when the incident-adverse events/dispensation ratios were calculated. Conclusion: This study reveals a negligible level of adverse events, given the known low sensitivity of the detection methods of incidents/adverse events, which implies the need to develop specific alarms in Palliative Care (AU)


Assuntos
Humanos , Masculino , Feminino , Idoso , Idoso de 80 Anos ou mais , Dano ao Paciente/prevenção & controle , Cuidados Paliativos na Terminalidade da Vida/organização & administração , Gestão da Segurança/organização & administração , Estudos Retrospectivos , Erros Médicos/estatística & dados numéricos , Notificação , Acidentes por Quedas/estatística & dados numéricos
SELEÇÃO DE REFERÊNCIAS
DETALHE DA PESQUISA