Incidentes de seguridad de los pacientes que involucran el bloqueo neuromuscular: análisis de los informes nacionales del Reino Unido y los datos de aprendizaje del sistema desde 2006 a 2008.

Incidentes de seguridad de los pacientes que involucran el bloqueo neuromuscular: análisis de los informes nacionales del Reino Unido y los datos de aprendizaje del sistema desde 2006 a 2008. Patient safety incidents involving neuromuscular blockade: analysis of the UK National Reporting and Learning System data from 2006 to 2008. Arnot-Smith J, Smith AF. Royal Bolton Hospital Foundation Trust, Bolton, UK. Anaesthesia. 2010 Nov;65(11):1106-13. doi: 10.1111/j.1365-2044.2010.06509.x.   Abstract Neuromuscular blockade is a powerful anaesthetic tool that has the potential for significant adverse outcomes. We sought to explore the national picture by analysing incidents relating to neuromuscular blockade in anaesthesia from the National Reporting and Learning System from England and Wales between 2006 and 2008. We searched the database of incidents using SNOMED CT search terms and reading the free text of relevant incidents. There were 231 incidents arising from the use or reversal of neuromuscular blocking agents. The main themes identified were: non-availability of drugs (45 incidents, 19%), possible unintentional awareness under general anaesthesia (42 incidents, 18%), potential allergic reaction (31 incidents, 13%), problems with reversal of blockade (13 incidents, 6%), storage (13 incidents, 6%) and prolonged apnoea (11 incidents, 5%). We make recommendations to reduce human error in the use of neuromuscular blocking agents and on future incident reporting in anaesthesia.  Link para bajar el artículo en PDF http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2044.2010.06560.x/pdf

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