Errores médicos / Medical errors

Marzo 4, 2016. No. 2255

Reducción de errores se asocia a su registro prospectivo A reduction in errors is associated with prospectively recording them. Oremakinde AA, Bernstein M. J Neurosurg. 2014 Aug;121(2):297-304. doi: 10.3171/2014.5.JNS132341. Epub 2014 Jun 13. Abstract OBJECT: Error recording and monitoring is an important component of error prevention and quality assurance in the health sector given the huge impact of medical errors on the well-being of patients and the financial loss incurred by health institutions. With this in mind, assessing the effect of reporting errors should be a cause worth pursuing. The object in this study was to examine the null hypothesis that recording and publishing errors do not affect error patterns in a clinical practice. METHODS: Intraoperative errors and their characteristics were prospectively recorded between May 2000 and May 2013 in the neurosurgical practice of the senior author (M.B.). The error pattern observed between May 2000 and August 2006, which has been previously described (Group A), was compared with the error pattern observed between September 2006 and May 2013 (Group B). RESULTS: A total of 1108 cases in Group A and 974 cases in Group B were surgically treated. A total of 2684 errors were recorded in Group A, while 1892 errors were recorded in Group B. The ratios of cranial to spinal procedures performed in Groups A and B were 3:1 and 10:1, respectively, while the ratios of general to local anesthesia in the two groups were 2:1 and 1.3:1, respectively (p < 0.0001 for both). There was a significantly decreased proportion of cases with error (87% to 83%, p < 0.006), mean errors per case (2.4 to 1.9, p < 0.0001), proportion of error-related complications (16.7% to 5.5%, p < 0.002), and clinical impacts of error (2.7% to 1.0%, p < 0.0001) in Group B compared with Group A. Errors in Group B tended to be more preventable than those in Group A (85.8% vs 78.5%, p < 0.0001). A significant reduction was also noticed with most types of error. A descending trend in the mean errors per case was demonstrated from the years 2001 to 2012; however, an increased severity of errors (22.6% to 29.5%, p < 0.0001) was recorded in Group B compared with Group A. CONCLUSIONS: Data in this study showed that the act of recording errors might alter behaviors, resulting in fewer errors. KEYWORDS: ASA = American Society of Anesthesiologists; error recording; intraoperative error; neurosurgery; prospective study PDF Errores de cognición detectados en anestesiología. Revisión de la literatura y estudio piloto Cognitive errors detected in anaesthesiology: a literature review and pilot study. Stiegler MP, Neelankavil JP, Canales C, Dhillon A. Br J Anaesth. 2012 Feb;108(2):229-35. doi: 10.1093/bja/aer387. Epub 2011 Dec 8. Abstract BACKGROUND: Cognitive errors are thought-process errors, or thinking mistakes, which lead to incorrect diagnoses, treatments, or both. This psychology of decision-making has received little formal attention in anaesthesiology literature, although it is widely appreciated in other safety cultures, such as aviation, and other medical specialities. We sought to identify which types of cognitive errors are most important in anaesthesiology. METHODS: This study consisted of two parts. First, we created a cognitive error catalogue specific to anaesthesiology practice using a literaturereview, modified Delphi method with experts, and a survey of academic faculty. In the second part, we observed for those cognitive errors during resident physician management of simulated anaesthesiology emergencies. RESULTS: Of >30 described cognitive errors, the modified Delphi method yielded 14 key items experts felt were most important and prevalent in anaesthesiology practice (Table 1). Faculty survey responses narrowed this to a 'top 10' catalogue consisting of anchoring, availability bias, premature closure, feedback bias, framing effect, confirmation bias, omission bias, commission bias, overconfidence, and sunk costs (Table 2). Nine types of cognitive errors were selected for observation during simulated emergency management. Seven of those nine types of cognitive errorsoccurred in >50% of observed emergencies (Table 3). CONCLUSIONS: Cognitive errors are thought to contribute significantly to medical mishaps. We identified cognitive errors specific to anaesthesiology practice. Understanding the key types of cognitive errors specific to anaesthesiology is the first step towards training in metacognition and de-biasing strategies, which may improve patient safety. PDF Manejo de los recursos en la crisis intraoperatoria durante cirugía toracoscópica asistida por video en pacientes sin intubar. Intraoperative crisis resource management during a non-intubated video-assisted thoracoscopic surgery. Navarro-Martínez J, Gálvez C, Rivera-Cogollos MJ, Galiana-Ivars M, Bolufer S, Martínez-Adsuar F. Ann Transl Med. 2015 May;3(8):111. doi: 10.3978/j.issn.2305-5839.2015.04.14. Abstract The management of surgical and medical intraoperative emergencies are included in the group of high acuity (high potential severity of an event and the patient impact) and low opportunity (the frequency in which the team is required to manage the event). This combination places the patient into a situation where medical errors could happen more frequently. Although medical error are ubiquitous and inevitable we should try to establish the necessary knowledge, skills and attitudes needed for effective team performance and to guide the development of a critical event. This strategy would probably reduce the incidence of error and improve decision-making. The way to apply it comes from the application of the management of critical events in the airline industry. Its use in a surgical environment is through the crisis resource management (CRM) principles. The CRM tries to develop all the non-technical skills necessary in a critical situation, but not only that, also includes all the tools needed to prevent them. The purpose of this special issue is to appraise and summarize the design, implementation, and efficacy of simulation-based CRM training programs for a specific surgery such as the non-intubated video-assisted thoracoscopic surgery. KEYWORDS: Crisis; anesthesia; intraoperative complications; thoracic surgery PDF

Anestesiología y Medicina del Dolor 52 664 6848905 vwhizar@anestesia-dolor.org anestesia-dolor.org Copyright © 2015

Tres nuevos analgésicos aprobados. Una actualizació

Febrero 27, 2016. No. 2249

Tres nuevos analgésicos aprobados. Una actualización Three newly approved analgesics: an update. Saraghi M, Hersh EV. Anesth Prog. 2013 Winter;60(4):178-87. doi: 10.2344/0003-3006-60.4.178. Abstract Since 2008, three new analgesic entities, tapentadol immediate release (Nucynta) diclofenac potassium soft gelatin capsules (Zipsor), and bupivacaine liposome injectable suspension (EXPAREL) were granted US Food and Drug Administration (FDA) approval to treat acute pain. Tapentadol immediate-release is a both a mu-opioid agonist and a norepinephrine reuptake inhibitor, and is indicated for the treatment of moderate to severe pain. Diclofenac potassium soft gelatin capsules are a novel formulation of diclofenac potassium, which is a nonsteroidal anti-inflammatory drug (NSAID), and its putative mechanism of action is through inhibition of cyclooxygenase enzymes. This novel formulation of diclofenac allows for improved absorption at lower doses. Liposomal bupivacaine is a new formulation of bupivacaine intended for single-dose infiltration at the surgical site for postoperative analgesia. Bupivacaine is slowly released from this liposomal vehicle and can provide prolonged analgesia at the surgical site. By utilizing NSAIDs and local anesthetics to decrease the transmission of afferent pain signals, less opioid analgesics are needed to achieve analgesia. Since drug-related adverse events are frequently dose related, lower doses from different drug classes may be employed to reduce the incidence of adverse effects, while producing synergistic analgesia as part of a multimodal analgesic approach to acute pain. PDF

Anestesiología y Medicina del Dolor 52 664 6848905 vwhizar@anestesia-dolor.org anestesia-dolor.org Copyright © 2015

Bibliotecas. Noticias

bibliotecas

NOTICIAS

Argentina y Haití, unidas por un convenio entre dos bibliotecas
Nuevo Diario de Santiago del Estero
a Biblioteca Popular Almafuerte concretó el ansiado proyecto de firmar un convenio de hermandad con la BibliotecaEl Club de la Amistad, de la ...




Periódico AM

Mejoran todas las bibliotecas
Periódico AM
El Gobierno Municipal, a través de la Dirección de Obras Públicas, y supervisada por el Comisión de Cultura del Ayuntamiento, está mejorando las ...




Noticiasdel6.com

El municipio recibe donaciones para bibliotecas barriales
Noticiasdel6.com
La Municipalidad de Posadas recibe donaciones de libros con el propósito de armar bibliotecaspopulares municipales en los distintos barrios de la ...




Misiones OnLine

El Municipio posadeño recibe donaciones para bibliotecas barriales
Misiones OnLine
El gobierno de Posadas recibe donaciones de libros con el fin de armar bibliotecas populares municipales en los distintos barrios de la ciudad.




Teleprensa periódico digital

La Red Municipal de Bibliotecas organiza rutas literarias en marco de la segunda edición de la ...
Teleprensa periódico digital
SEVILLA.-El Instituto de la Cultura y las Artes de Sevilla (ICAS) participa desde la Red Municipal deBibliotecas y el Antiquarium en la segunda ...




ecodiario

LA FUNDACIÓN BOTÍN LAMENTA EL FALLECIMIENTO DE JOSÉ ANTONIO LASHERAS
Lainformacion.com
La Fundación Botín ha expresado su más profundo pesar por el fallecimiento de José Antonio Lasheras, director del Museo Nacional y Centro de ...
Méndez de Vigo destaca que el director del Museo de Altamira era uno de los mayores ... -Lainformacion.com
El Gobierno cántabro lamenta la muerte del director del Museo Altamira, "el gran valedor de la ... - Lainformacion.com
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La Biblioteca de Bizarain se abre a los vecinos del barrio de Beraun
Diario Vasco
El Ayuntamiento, representado por el alcalde, Julen Mendoza, y Bizarain Ikastola, representada por su directora, Belén Ugalde, firmaron ayer un ...



Llevan bibliotecas a las plazas
El Heraldo del Bajío (Comunicado de prensa)
En el Parque “La Alameda” se llevó a cabo la inauguración del programa Biblioteca en su Plaza, promovido por el Instituto Estatal de la Cultura.




Crónica Global

Una exposición inicia el programa del Ayuntamiento para recordar a Cervantes
Telemadrid
Una exposición itinerante sobre la vida y obra de Miguel de Cervantes, que se abre este lunes en labiblioteca pública municipal Mario Vargas Llosa, ...
Una exposición inicia el programa del Ayuntamiento para recordar a Cervantes - La Vanguardia
Diputación y Biblioteca del Estado en Ciudad Real se unen para celebrar el IV Centenario de ... - forosocuellamos
Los Reyes amplían su agenda e inaugararán la exposición de la BNE en torno al mito de Cervantes -Lainformacion.com
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Blasting News

Una biblioteca humana: en vez de libros, lees a personas
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Generalmente las bibliotecas son lugares no sólo de lectura, sino también de discusión y espacios para generar nuevos amigos. La biblioteca ...

Infecciones y lactancia Actualidades 2016

Estimado Pediatra te invito al Seminario de Pediatría, Cirugía Pediátrica y Lactancia Materna. El día 2 Marzo 2016 las 21hrs (Centro, México DF, Guadalajara y Lima Perú) a la Conferencia: “Infecciones y lactancia Actualidades 2016” por la “Dra. Claudia López Enriquez”, Infectologo , Pediatra de la Cd. de México DF La sesión inicia puntualmente las 21 hrs.
Para entrar a la Sala de Conferencia:
1.- hacer click en la siguiente liga, o cópiala y escríbela en tu buscador http://connectpro60196372.adobeconnect.com/actualidades_if_lactancia/
2.- “Entra como Invitado” Escribes tu nombre y apellido en el espacio en blanco
3.- Hacer click en el espacio que dice “Entrar en la Sala”
5.- A disfrutar la conferencia
6.- Recomendamos que dejes tu Nombre Completo, Correo electrónico y que participes.


Henrys


Dr. Enrique Mendoza López Webmaster: CONAPEME Coordinador Nacional: Seminario Ciberpeds-Conapeme Av La clinica 2520-310 Colonia Sertoma ,Mty N.L. México CP 64710 Tel-Fax 52 81 83482940 y 52 81 81146053 Celular 8183094806 www.conapeme.org www.pediatramendoza.com enrique@pediatramendoza.com emendozal@yahoo.com.mx
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Revistas con acceso híbrido / Hybrid access journals

Febrero 28, 2016. No. 2250

Anesthesia and  Analgesia January 2015 - Volume 120 - Issue 1.pp: 1-258 Revista / Journal Anesthesia and  Analgesia February 2015 - Volume 120 - Issue 2, pp: 259-495 PDF Academic Medicine February 2016 - Volume 91 - Issue 2,pp: 155-284 Revista / Journal Advances in Neonatal Care October 2014 - Volume 14 - Supplement 1 5S, pp: S1-S33 PDF The American Journal of the Medical Science April 2015 - Volume 349 - Issue 4, pp: 287-377,e4-e4 PDF Annals of Pediatric Surgery October 2013 - Volume 9 - Issue 4. pp: 131-158 Revista / Journal

Anestesiología y Medicina del Dolor 52 664 6848905 vwhizar@anestesia-dolor.org anestesia-dolor.org Copyright © 2015