Carrillo-Esper R

Language: Spanish
References: 37
Page: 103-110
PDF size: 620.72 Kb.

ABSTRACT

While anesthesia is generally considered safe today, anesthesia errors can be made, leading to disastrous consequences. Current statistics indicate that 1 in every 200,000 to 300,000 patients die due to anesthesia complications. Critical incidents defined as an event that could, if no detected and corrected, lead to a serious patient injury, occur with surprising frequency during anesthesia. Fortunately the majory of the critical incidents fail to harm the patient. Many studies suggest that humans and system errors are a major contributors to the occurrence of anesthesia mishaps. Anesthesiologists must to research and explore error and it causes, and attempt to minimize and/or eliminate error at all reasonable cost. A culture of safety has developed in anesthesia practice by the adoption of a more systems-based approach by many anesthesia departments, groups and organizations interested in optimizing outcome of anesthesia care. The aim of this paper is to review and analyze the error and critical incidents in anesthesiology and its determinants, consequences, prevention and implementation of processes leading to its eradication.

REFERENCES

1. Oser BA, Chen R, Yee DA. Medication errors in anesthetic practice: a survey of 687 practitioners. Canadian J Anesth 2001;48:139-146.

2. Flanagan JC. The critical incident technique. Psychological Bulletin 1954;51:327-358.

3. Cooper JB, Newbower RS, Long CD, McPeek B. Preventable anesthesia mishaps: a study of human errors. Anesthesiology 1978;49:399-406.

4. Katz R, Lagasse R. Factors influencing the reporting of adverse outcomes to a quality management program. Anesth Analg 2000;90:344-350.

5. Beecher HK. The first anesthesia death with some remarks suggested by it on the fields of the laboratory and the clinic in the appraisal of new anesthetic agents. Anesthesiology 1941;2:443-449.

6. Cooper JB, Newbower RS, Kitz JR. An analysis of major errors and equipment failures in anesthesia management: Considerations for preventing and detection. Anesthesiology 1984;60:34-42.

7. Botney R. Improving patient safety in anesthesia: a success history. Int J Randiant Oncol Biol Phys 2008;71:182-186.

8. Reason J. Human Error. Cambridge University Press, 1990.

9. Vallongo BM, Cordoví AL. Error humano y paro cardíaco intraoperatorio: ¿Un problema actual? Rev Cub Anestesiol Reanim 2010;9:3-13.

10. Reason J. Safety in the operating theatre. Part 2: Human error and organizational failure. Qual Saf Health Care 2005;14:56-60.

11. Marcus MA. Human factors in pediatric anesthesia incidents. Ped Anesth 2006;16:242-250.

12. Liu EH, Koh KF. A prospective audit of critical incidents in anesthesia in a university teaching hospital. Ann Acad Med Singapore 2003;32:814-822.

13. Webster CS, Merry AF, Larsson L. The frequency and nature of drug administration error during anaesthesia. Anaesth Int Care 2001;29:494-500.

14. Chopra V, Bovill JG, Spierdijk J. Accidents, near accidents and complications during anaesthesia. A retrospective analysis of a 10-year period in a teaching hospital. Anaesthesia 1990;45:3-6.

15. Leape LL. Reporting of adverse events. N Engl J Med 2002;347:1633-1638.

16. Aheysekera A, Bergman LJ, Kluger MT, Short TG. Drug error in anesthetic practice: a review of 896 reports from Australian Incident Monitoring Study database. Anaesthesia 2005;60:220-227.

17. Khan FA, Hoda MQ. Drug related critical incidents. Anaesthesia 2005;60:48-52.

18. Irita K, Tsuzaki K, Sawa T, Sanuki M, Makita K, Kobayashi Y. Critical incidents due to drug administration error in the operating room: an analysis of 4,291,925 anesthetics over a 4 year period. Masui 2004;53:577-584.

19. Chen RJ, Yee DA. Medication errors in anesthetic practice: a survey of 687 practitioners. Can J Anesth 2001;48:139-146.

20. Webster CS, Merry AF, Larsson L, Mc Grath KA, Weller J. The frequency and nature of drug administration error during anaesthesia. Anaesth Intensive Care 2001;29:494-500.

21. Flyn E, Barker K, Ginette A. Comparison of methods for detecting medication errors in 36 hospitals and skilled-nursing facilities. Am J Health Syst Pharm 2002;59:436-446.

22. Kondrak G, Dorr B. Automatic identification of confusable drugs names. Artif Intell Med 2006;36:29-42.

23. Haslam GM, Sims C, McIndoe AK, Saunders J, Lovell AT. Higj latent drug administration error rates associated with the introduction of the international colour coding syringe labeling system. Eur J Anaesth 2006;23:165-168.

24. Fasting S, Gigvold SE. Adverse drug errors in anesthesia and the impact of coloured syringe labels. Can J Anaesth 2000;47:1060-1067.

25. Wikinski JA, Piaggio AN, Deluca CA, Paladino MA. Responsabilidad profesional del anestesiólogo y riesgo anestésico. Rev Argent Anestesiol 1996;54:110-135.

26. Barreiro G, Gorat J. Incidentes críticos en anestesia. Ver Urug Anest Analg y Reanim 1993;51:83-90.

27. Reason J. Human error: models and management. BMJ 2000;320: 768-773.

28. Leape LL. Error in Medicine. JAMA 1994;272:851-857.

29. Leape LL, Brennan TA, Laird N, Lawthers AG, Localio AR, Barnes BA, et al. The nature of adverse events in hospitalized patients: Results of the Harvard Medical Practice Study II. N Engl J Med 1991;324:377-384.

30. Runciman WB, Williamson JA, Deakin A, Benveniste KA, Bannon K, Hibbert PD. An integrated framework for safety, quality and risk management: an information and incident management system based on a universal patient safety classification. Qual Saf Health Care 2006;15:82-90.

31. Gómez-Arnau JI, Bartolomé A, Santa-Úrsula JA, González A, García del Valle S. Sistemas de comunicación de incidentes y seguridad del paciente en anestesia. Rev Esp Anestesiol Reanim 2006;53:488-99.

32. Lunn JN. Preventable anaesthetic mortality and morbidity. Report of an international symposium. Anaesthesia 1985;40:79-83.

33. JCAHO. Sentinel events forms and tools. Oakbrook Terrace: Joint Commission on Accreditation of Healthcare Organizations; c2005. Disponible en http://www.jcaho.org/accredited+organizations/sentinel+event/se_index.htm

34. Vincent CA. Analysis of clinical incidents: a window on the system not a search for root causes. Qual Saf Health Care 2005;13:242-247.

35. Nine Patient Safety Solutions. Consultado en www.ccforpatient.safety.org/Nine-Patient-Safety-Solutions-Pres-Kit

36. Consejo de Salubridad General. www.csg.salud.gob.mx

37. CONAMED. Recomendaciones para anestesiología http://www.conamed.gob.mx/interiores.php ruta=http://www.conamed.gob.mx/prof_salud/&destino=recomendaciones.php