| Incidentes críticos durante anestesia en un país en desarrollo: Auditoría retrospectiva |
Critical incidents during anesthesia in a developing country: A retrospective audit.
Amucheazi AO, Ajuzieogu OV.
Anesth Essays Res 2010;4:64-8
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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Informes de incidentes críticos y el aprendizaje
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Critical incident reporting and learning.
Mahajan RP.
Division of Anaesthesia and Intensive Care, Queen's Medical Centre, Nottingham NG7 2UH, UK. ravi.mahajan@nottingham.ac.uk
Br J Anaesth. 2010 Jul;105(1):69-75.
Abstract
The success of incident reporting in improving safety, although obvious in aviation and other high-risk industries, is yet to be seen in health-care systems. An incident reporting system which would improve patient safety would allow front-end clinicians to have easy access for reporting an incident with an understanding that their report will be handled in a non-punitive manner, and that it will lead to enhanced learning regarding the causation of the incident and systemic changes which will prevent it from recurring. At present, significant problems remain with local and national incident reporting systems. These include fear of punitive action, poor safety culture in an organization, lack of understanding among clinicians about what should be reported, lack of awareness of how the reported incidents will be analysed, and how will the reports ultimately lead to changes which will improve patient safety. In particular, lack of systematic analysis of the reports and feedback directly to the clinicians are seen as major barriers to clinical engagement. In this review, robust systematic methodology of analysing incidents is discussed. This methodology is based on human factors model, and the learning paradigm which emphasizes significant shift from traditional judicial approach to understanding how 'latent errors' may play a role in a chain of events which can set up an 'active error' to occur. Feedback directly to the clinicians is extremely important for keeping them 'in the loop' for their continued engagement, and it should target different levels of analyses. In addition to high-level information on the types of incidents, the feedback should incorporate results of the analyses of active and latent factors. Finally, it should inform what actions, and at what level/stage, have been taken in response to the reported incidents. For this, local and national systems will be required to work in close cooperation, so that the lessons can be learnt and actions taken within an organization, and across organizations. In the UK, a recently introduced speciality-specific incident reporting system for anaesthesia aims to incorporate the elements of successful reporting system, as presented in this review, to achieve enhanced clinical engagement and improved patient safety.http://bja.oxfordjournals.org/content/105/1/69.full.pdf+html
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| ¿Acaso nuestra deprivación de sueño afecta la seguridad del paciente? |
Does our sleep debt affect patients' safety?
Tewari A, Soliz J, Billota F, Garg S, Singh H.
Department of Anesthesiology, Dayanand Medical College & Hospital, Ludhiana, India.
Indian J Anaesth. 2011 Jan;55(1):12-7.
Abstract
The provision of anaesthesia requires a high level of knowledge, sound judgement, fast and accurate responses to clinical situations, and the capacity for extended periods of vigilance. With changing expectations and arising medico-legal issues, anaesthesiologists are working round the clock to provide efficient and timely health care services, but little is thought whether the "sleep provider" is having adequate sleep. Decreased performance of motor and cognitive functions in a fatigued anaesthesiologist may result in impaired judgement, late and inadequate responses to clinical changes, poor communication and inadequate record keeping, all of which affect the patient safety, showing without doubt the association of sleep debt to the adverse events and critical incidents. Perhaps it is time that these issues be promptly addressed to prevent the silent perpetuation of a problem that is pertinent to our health and our profession. We endeavour to focus on the evidence that links patient safety to fatigue and sleepiness of health care workers and specifically on anaesthesiologists. The implications of sleep debt are deep on patient safety and strategies to prevent this are the need of the hourhttp://www.ijaweb.org/temp/IndianJAnaesth55112-5790671_160506.pdf
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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 Servicios Profesionales de Anestesiología y Medicina del Dolor
Centro Médico del Noroeste
Tijuana, B.C., México
Anestesia en México 2007;19:88-98.
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 riesgohttp://ww.anestesiaenmexico.org/RAM9/RAM2007-19-2/006.pdf .
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