2016, Number 4
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Rev Mex Anest 2016; 39 (4)
Has rocuronium bromide analgesic properties? Medical mistakes, apropos of a case
Ruales S, Sánchez A, Ortega P, Santana E, Palomeque A
Language: Spanish
References: 20
Page: 299-302
PDF size: 183.67 Kb.
ABSTRACT
A sentinel event happened in the operating room of the Hospital de los Valles in Quito, for lack of labeling the drugs, which would be used in the anesthetic procedure. Currently, it is shown that human error is part of the statistics of morbidity and mortality of different medical procedures in hospitalized patients, and because of the danger of the drugs used in the Area of Anesthesia, these have become one of the main causes of error, with the result of serious adverse events that may even cause death. The importance of knowledge and having the necessary tools to act in the emergencies is also demonstrated. In this case a controversial drug because of its cost, sugammadex.
REFERENCES
Kohn L, Corrigan J, Donaldson M. To err is human: building a safer health system.1 edition. Washington, D.C: National Academy Press; 2000.
Orser BA, Chen RJ, Yee DA. Medication errors in anesthetic practice: a survey of 687 practitioners. Can J Anaesth. 2001;48:139-146.
Valentin A, Capuzzo M, Guidet B, Moreno R, Metnitz B, Bauer P, et al. Errors in administration of parenteral drugs in intensive care units: multinational prospective study. BMJ. 2009;338:b814.
Abeysekera A, Bergman IJ, Kluger MT, Short TG. Drug error in anaesthetic practice: a review of 896 reports from the Australian incident monitoring study database. Anaesthesia. 2005;60:220-227.
Orser BA, Hyland S, U D, Sheppard I, Wilson CR. Review article: improving drug safety for patients undergoing anesthesia and surgery. Can J Anaesth. 2013;60:127-135.
Ogboli-Nwasor E. Medication errors in anaesthetic practice: a report of two cases and review of the literature. Afr Health Sci. 2013;13:845-849.
Webster CS, Merry AF, Larsson L, McGrath KA, Weller J. The frequency and nature of drug administration error during anaesthesia. Anaesth Intensive Care. 2001;29:494-500.
Otero LM. Nuevas iniciativas para mejorar la seguridad de la utilización
de los medicamentos en los hospitales. Rev Esp Salud Pública. 2004;77:3.
Botney R. Improving patient safety in anesthesia: a success story? Int J Radiat Oncol Biol Phys. 2008;71:S182-186.
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.
Flynn EA, Barker KN, Pepper GA, Bates DW, Mikeal RL. Comparison of methods for detecting medication errors in 36 hospitals and skilled-nursing facilities. Am J Health Syst Pharm. 2002;59:436-446.
Merry AF, Webster CS, Hannam J, Mitchell SJ, Henderson R, Reid P, et al. Multimodal system designed to reduce errors in recording and administration of drugs in anaesthesia: prospective randomised clinical evaluation. BMJ. 2011;343:d5543.
Eichhorn J. APSF hosts medication safety conference. Consensus group defines challenges and opportunities for improved practice. Newsletter Spring. 2010;25: .
Vázquez-Frías JA, Villalba-Ortiz P, Villalba-Caloca J, Montiel-Falcón H, Hurtado-Reyes C. El error en la práctica médica. ¿Qué sabemos al respecto? 2011;56:49-57.
Glavin RJ. Drug errors: consequences, mechanisms, and avoidance. B J Anaesth. 2010;105:76-82.
López-Rabassa SI, Paz-Estrada C, López-Lazo S, González-Rodríguez GS, Rabassa SN. Error relativo a medicamentos en Anestesiología. ¿Cuál es la problemática? Rev Mex Anestesiol. 2012;35:275-282.
Khan FA, Hoda MQ. Drug related critical incidents. Anaesthesia. 2005;60:48-52.
Birks RJ, Simpson PJ. Syringe labelling-an international standard. Anaesthesia. 2003;58:518-519.
The Joint Commission. 2006 National Patient Safety Goals. [Internet] Available in: http://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/
Choy CY. Critical incident monitoring in anaesthesia. Curr Opin Anaesthesiol. 2008;21:183-186.