jueves, 3 de abril de 2014


Las complicaciones en medicina son parte de nuestra práctica profesional ya que errar es parte del ser humano. Un grupo de complicaciones no relacionadas con nuestros errores son secundarias a las respuestas fisiológicas del organismo a los procedimientos médicos o a alergias no esperadas. Hoy iniciamos envíos con información sobre complicaciones. Disfrute su lectura
Complications in medicine are part of our practice since err is part of being human. A group of complications unrelated to our mistakes are secondary to the physiological responses of the organism to unexpected medical procedures or allergies. Today we begin with fresh information on complications. Enjoy your reading.

Complicações na medicina fazem parte da nossa prática desde err faz parte do ser humano. Um grupo de complicações não relacionadas com os nossos erros são secundárias às respostas fisiológicas do organismo aos procedimentos médicos inesperados ou alergias. Hoje começamos com novas informações sobre complicações. Boa leitura.

Definiendo los errores relacionados a la tecnología en salud: novedades desde errar es humano

Defining health information technology-related errors: new developments since to err is human.
Sittig DF, Singh H.
Arch Intern Med. 2011 Jul 25;171(14):1281-4. doi: 10.1001/archinternmed.2011.327.
Despite the promise of health information technology (HIT), recent literature has revealed possible safety hazards associated with its use. The Office of the National Coordinator for HIT recently sponsored an Institute of Medicine committee to synthesize evidence and experience from the field on how HIT affects patient safety. To lay the groundwork for defining, measuring, and analyzing HIT-related safety hazards, we propose that HIT-related error occurs anytime HIT is unavailable for use, malfunctions during use, is used incorrectly by someone, or when HIT interacts with another system component incorrectly, resulting in data being lost or incorrectly entered, displayed, or transmitted. These errors, or the decisions that result from them, significantly increase the risk of adverse events and patient harm. We describe how a sociotechnical approach can be used to understand the complex origins of HIT errors, which may have roots in rapidly evolving technological, professional, organizational, and policy initiatives

Errar es Humano Informe de casos de dos accidentes militares aéreos: Posibles mecanismos

To Err is Human Case Reports of Two Military Aircraft Accidents: Possible mechanisms of human failure.
Dikshit MB.
Sultan Qaboos Univ Med J. 2010 Apr;10(1):120-5. Epub 2010 Apr 17.
It has been postulated that pilot error or in-flight incapacitation may be the main contributory factors to 70-80% of aircraft accidents. Two fatal aircraft accidents are presented in which either of the above possibilities may have played a role. The first case report describes an erroneous decision by a fighter pilot to use a seat position adjustment of the ejection seat leading to fatal injuries when he had to eject from his aircraft. Injuries to the body of the pilot, and observations on the state of his flying clothing and the ejection seat were used to postulate the mechanism of fatal injury and establish the cause of the accident. The second case report describes the sequence of events which culminated in the incapacitation of a fighter pilot while executing a routine manouevre. This resulted in a fatal air crash. Possible contributions of environmental factors which may have resulted in failure of his physiological mechanisms are discussed.
KEYWORDS:Aviation accident, Ejection seat, Flying clothing, Gravity-induced loss of consciousness, Incapacitation, Injury, Pilot error, Spatial disorientation, in-flight


Trauma y la compasión inducido medicamente: reflexiones desde la punta de la atención.
Medically induced trauma and compassion: Reflections from the sharp end of care.
Pelt Fv. Indian J Anaesth [serial online] 2010 [cited 2014 Mar 23];54:283-5.
Since the Institute of Medicine's landmark report 'To Err is Human' in 1999, wherein it has been estimated that up to 100,000 patient lives are lost each year in the United States due to medical error, healthcare in the United States as well as globally has invested great effort and resources in the improvement of quality and patient safety. Although research and reporting is typically focused on process improvement methodologies and the changes being implemented in healthcare delivery, very little attention has been focused on the management of adverse medical events, specifically the impact that these events have on patients, families and care providers. It would be a rare care provider who has not been directly involved in an adverse medical event or who has not witnessed a colleague having been involved in an adverse event. Most adverse medical events are shrouded in secrecy and gaining the opportunity to share the experience in an open and meaningful way is extremely difficult.



Anestesiología y Medicina del Dolor

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