Incidentes críticos durante anestesia en un país en desarrollo; Una auditoría restrospectiva |
Critical incidents during anesthesia in a developing country: A retrospective audit
AO Amucheazi, OV Ajuzieogu
Department of Anaesthesia, College of Medicine University of Nigeria, Enugu campus, Nigeria
Anesth Essays and Research 2010:4:64-68. DOI: 10.4103/0259-1162.73508
Background: Critical incidents occur inadvertently where ever humans work. Reporting these incidents and near misses is important in learning and prevention of future mishaps. The aim of our study was to identify the incidence, outcome and potential risk factors leading to critical incidents during anaesthesia in a tertiary care teaching hospital and attempt to suggest preventive strategies that will improve patient care. Materials and Methods: A retrospective audit of all anaesthesia charts for documented critical incidents over a 12 month period was carried out. Age and ASA classification of patient, urgency of surgery, timing of the incident, body system involved and the grade of the anaesthetists were noted. The data collected was analysed using the SPSS software. Results: Fourteen incidents were documented in 54 patients, giving a frequency of 0.071. More females suffered critical incidents. Patients in the 4 th and 5 th decades of life were noted to be more susceptible. Airway and cardiovascular incidents were the commonest. Anaesthetists with less than 6 years experience were involved in more mishaps. Conclusion: We conclude that airway mishaps and cardiovascular instability were the commonest incidents especially in the hands of junior anaesthetists.
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Muerte o Daño Neural por Anestesia en Pacientes de Bajo riesgo. Análisis de 25 casos y del Impacto a Largo Plazo en los Anestesiólogos. |
Dr. Víctor M. Whizar-Lugo, Dr. Roberto Cisneros-Corral, Lic. Jesús A. Maldonado-Romero
Anestesia en México 2007;19(2):88-98
Resumen
Aunque la anestesia es un procedimiento seguro, tienen una mortalidad de 1 por cada 10,000 casos. Existen por lo menos cuatro causas comunes de falla por anestesia que son responsables de la mayoría de las muertes: intubación difícil, broncoaspiración, ventilación inadecuada, y falla de restitución de volumen. Objetivo. Revisar las muertes por anestesia y daño neurológico severo en pacientes de bajo riesgo anestésico, de los factores implicados y el impacto en los anestesiólogos involucrados. Método. Se trata de un estudio prospectivo, observacional en el cual se revisaron las muertes de 25 pacientes ASA 1 y 2 que murieron en Tijuana de 1985 a 1990 debido a complicaciones por anestesia. Los expedientes médicos y legales se analizaron para determinar las circunstancias, hechos y factores involucrados. También analizamos el impacto a largo plazo de estas muertes en los anestesiólogos involucrados. Resultados. Hubo 25 casos de daño neural severo o muerte por anestesia; 8 hombres, 14 mujeres, con edad de 2 a 69 años (media 35.5), 16 casos fueron manejados con anestesia general (14 muertos, 1 daño cerebral severo 1 daño motor) y 9 con regional (4 muertes, 4 daño neural periférico, 1 daño cerebral). Hubo error humano en 24 casos (17 del anestesiólogo, 4 de la enfermera, 2 de personal no médico). Hubo 9 demandas y un anestesiólogo se suicidó. Discusión. El error humano fue la causa más frecuente de muerte o daño neurológico en nuestros casos de bajo riesgo. Aunque nuestros resultados son incompletos, muestran la necesidad que existe para desarrollar un sistema local orientado a disminuir la morbimortalidad por anestesia en nuestra ciudad.
Palabras clave: Muerte, daño neural, anestesia, bajo riesgo. |
| Presión de producción, errores médicos, y la verificación preanestésica |
Production pressure, medical errors, and the pre-anesthesia checkout
Samuel DeMaria Jr., Steven M. Neustein
M.E.J. ANESTH 20 (5), 2010 Abstract
Medical errors have rightly become an important societal and professional issue. While anesthesiology as a specialty has been at the forefront of the patient safety movement it is also subject to the same pressures for efficiency as any other business. Whether this pressure is at odds with the delivery of safe care is not yet clearly delineated. However, a theoretical framework of unsafe practices as well as a body of literature from other industries such as aviation suggests that production pressure may lead to unsafe practice. Also, it is unlikely that the common pressures encountered in the operating room (e.g., to reduce turnover times) have any positive financial impact for anesthesiology departments unless extra cases can be done each day. We include in this review a potential area for improvement and further research for anesthesiologists, the preanesthesia induction timeout. This crucial period of any anesthetic involves a high workload and is often the most hurried; this combination may be setting practitioners up to make errors. We suggest the use of checklists and timeouts to formalize this period and propose a useful seven-point list of crucial items and events needed before each anesthetic.
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