30 de agosto de 2011

Artigo: Human Factors Research in Anesthesia Patient Safety: Techniques to Elucidate Factors Affecting Clinical Task Performance and Decision Making

Matthew B Weinger and Jason Slagle

JAMIA 2002 9: S58-S63

ABSTRACT
Patient safety has become a major public concern. Human factors research in other high-risk fields has demonstrated how rigorous study of factors that affect job performance can lead to improved outcome and reduced errors after evidence-based redesign of tasks or systems. These techniques have increasingly been applied to the anesthesia work environment. This paper describes data obtained recently using task analysis and workload assessment during actual patient care and the use of cognitive task analysis to study clinical decision making. A novel concept of “non-routine events” is introduced and pilot data are presented. The results support the assertion that human factors research can make important contributions to patient safety. Information technologies play a key role in these efforts.

INTRODUCTION
In order to improve patient safety, it is critical to understand how clinical systems actually work, what factors make them work well (or not so well), and why adverse events occur. It is particularly important to elucidate the role clinicians play in medical system safety. Given the complexity of clinical processes and the large number of interdependent mediating variables, these types of questions may not be amenable to traditional empirical experimentation. In complex high-risk systems it is highly undesirable to wait for a serious accident to happen before analyzing a system’s safety attributes. Thus, non-medical domains such as nuclear power and aviation have employed human factors techniques to extract detailed information about system performance and risks to safety. We have adapted this approach to medicine, using anesthesia as the initial test bed.

The Anesthesia Work Domain
Anesthesiologists, like surgeons and emergency room physicians, work in a complex, rapidly changing, time-constrained and stressful work environment. The anesthesia domain is in many ways similar to aircraft cockpits, air traffic control rooms, and combat information centers where effective performance demands expert knowledge, appropriate problem-solving strategies, and fine motor skills. The safe administration of anesthesia requires vigilance (e.g., etection of changes in patient condition), time-sharing among multiple tasks, and the ability to rapidly make decisions and take actions. The anesthesiologist views his/her task as managing a single highly interactive system composed of the patient, clinical equipment, surgeons, other operating room (OR) personnel, and the broader OR environment. Primary goals include protecting the patient from harm and facilitating surgery. Intraoperative anesthesia care is divided into induction, maintenance (when surgery occurs), and emergence.


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26 de agosto de 2011

Artigo recomendado: Como o Anestesiologista Pode Contribuir para a Prevenção de Infecção no Paciente Cirúrgico


Fabiana Aparecida Penachi Bosco Ferreira, TSA, Maria Ligia Gomes Marin, Tânia Mara V. Strabelli, Maria José Carvalho Carmona, TSA


Revista Brasileira de Anestesiologia
Vol. 59, No 6, Novembro-Dezembro, 2009

RESUMO
Ferreira FAPB, Marin MLG, Strabelli TMV, Carmona MJC - Como o Anestesiologista Pode Contribuir para a Prevenção de Infecção no Paciente Cirúrgico.

JUSTIFICATIVA E OBJETIVOS: O paciente cirúrgico com infecção hospitalar, além de aumentar os custos hospitalares, pode não recuperar sua condição prévia e até morrer. Além dos riscos individuais bem estabelecidos, o desenvolvimento de infecção pós-operatória depende do procedimento a que será submetido, das condições hospitalares e do cirurgião. Apesar de haver muitos protocolos visando o controle da infecção, falta padronização de intervenções intraoperatórias visando a otimização desse paciente. Assim, esta revisão teve como objetivo discutir algumas dessas intervenções que são eficazes e necessárias, alertando o anestesiologista da sua importância na prevenção da infecção hospitalar.

CONTEÚDO: Nesta revisão foram abordadas as causas de infecção no paciente cirúrgico e discutiu-se como a adequada administração de antibióticos, o controle térmico e glicêmico e as estratégias de ventilação mecânica, hidratação e transfusão podem reduzir as taxas de infecção no paciente cirúrgico.

CONCLUSÕES: O anestesiologista é o profissional que deve intervir no intraoperatório com medidas simples para otimizar o atendimento do paciente cirúrgico e diminuir índices de infecção.

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24 de agosto de 2011

Curso de extensão: Dilemas acerca da vida humana: interfaces entre a Bioética e o Biodireito


Este curso é fruto da parceria firmada ente o Hospital HCor e o Centro Universitário São Camilo.

O curso será realizado sempre aos sábados, com início em 03/09.

Custo:  2 parcelas de R$ 200,00.

Local: Hospital HCor.

Inscrição: lidsantos@hcor.com.br

Vagas limitadas!


23 de agosto de 2011

Artigo recomendado: Postoperative mortality after inpatient surgery: Incidence and risk factors

Karamarie Fecho, Anne T Lunney, Philip G Boysen, Peter Rock, Edward A Norfleet


Therapeutics and Clinical Risk Management 2008:4(4) 681–688

Purpose: This study determined the incidence of and identifi ed risk factors for 48 hour (h) and 30 day (d) postoperative mortality after inpatient operations.

Methods: A retrospective cohort study was conducted using Anesthesiology’s Quality Indicator database as the main data source. The database was queried for data related to the surgical procedure, anesthetic care, perioperative adverse events, and birth/death/operation dates. The 48 h and 30 d cumulative incidence of postoperative mortality was calculated and data were analyzed using Chi-square or Fisher’s exact test and generalized estimating equations.

Results: The 48 h and 30 d incidence of postoperative mortality was 0.57% and 2.1%, respectively. Higher American Society of Anesthesiologists physical status scores, extremes of age, emergencies, perioperative adverse events and postoperative Intensive Care Unit admission were identifi ed as risk factors. The use of monitored anesthesia care or general anesthesia versus regional or combined anesthesia was a risk factor for 30 d postoperative mortality only. Time under anesthesia care, perioperative hypothermia, trauma, deliberate hypotension and invasive monitoring via arterial, pulmonary artery or cardiovascular catheters were not identifi ed as risk factors.

Conclusions: Our fi ndings can be used to track postoperative mortality rates and to test preventative interventions at our institution and elsewhere.

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18 de agosto de 2011

Artigo recomendado: Erros Farmacológicos na Prática Anestésica: Quatro Casos de Morbidades Não Fatais

Jose LLagunes Herrero, Carmen Reina, Lucrecia Blasco, Esperanza Fernandez, Miguel Plaza, Eva Mateo

Revista Brasileira de Anestesiologia
Vol. 60, No 1, Janeiro-Fevereiro, 2010

JUSTIFICATIVA E OBJETIVOS: Os anestesistas estão se preocupando mais em garantir segurança aos pacientes, enfatizando o desfecho cirúrgico e qualidade do atendimento no centro cirúrgico e em outras áreas do hospital. Na prática, não existe nenhum aspecto da Anestesiologia que seja mais importante no manuseio seguro dos pacientes do que a administração correta de fármacos.
Erros farmacológicos representam uma pequena percentagem dos problemas anestésicos, mas apresentam potencial de morbidade grave e consequências legais. O objetivo deste relato foi descrever quatro casos de erros medicamentosos (EM) raros no centro cirúrgico, sem consequências danosas para os pacientes e como sua análise e identificação evitaram o desenvolvimento de danos mais graves.

RELATO DOS CASOS: Quatro casos de sobredoses acidentais no centro cirúrgico antes da indução anestésica. A mesma seringa foi usada para preparar e diluir dois medicamentos diferentes. Portanto, esse erro foi causado pela presença do segundo medicamento. A toxicidade se manifestou com depressão respiratória e sedação temporárias, havendo necessidade de ventilação assistida, mas sem desfechos adversos.

CONCLUSÕES: Explicou-se como os medicamentos envolvidos e quando o erro cometido foram identificados para melhorar a prática clínica, reduzindo os erros medicamentosos. Enfatizamos a importância da informação e educação dos profissionais de saúde sobre novos medicamentos e seu processo de preparação, pois foi prática inaceitável em 2009.

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15 de agosto de 2011

Artigo recomendado: Wrong-Site and Wrong-Patient Procedures in the Universal Protocol Era

Analysis of a Prospective Database of Physician Self-reported Occurrences


Philip F. Stahel, MD; Allison L. Sabel, MD, PhD, MPH; Michael S. Victoroff, MD; Jeffrey Varnell, MD; Alan Lembitz, MD; Dennis J. Boyle, MD; Ted J. Clarke, MD; Wade R. Smith, MD; Philip S. Mehler, MD

Arch Surg. 2010;145(10):978-984

Objective: To determine the frequency, root cause, and outcome of wrong-site and wrong-patient procedures in the era of the Universal Protocol.

Design: Analysis of a prospective physician insurance database performed from January 1, 2002, to June 1, 2008. Deidentified cases were screened using predefined taxonomy filters, and data were analyzed by evaluation criteria defined a priori.

Setting: Colorado.

Patients: Database contained 27 370 physician selfreported adverse occurrences.

Main Outcome Measures: Descriptive statistics were generated to examine the characteristics of the reporting physicians, the number of adverse events reported per year, and the root causes and occurrence-related patient outcomes.

Results: A total of 25 wrong-patient and 107 wrong-site procedures were identified during the study period. Significant harm was inflicted in 5 wrong-patient procedures (20.0%) and 38 wrong-site procedures (35.5%). One patient died secondary to a wrong-site procedure (0.9%). The main root causes leading to wrong-patient procedures were errors in diagnosis (56.0%) and errors in communication (100%), whereas wrong-site occurrences were related to errors in judgment (85.0%) and the lack of performing a “time-out” (72.0%). Nonsurgical specialties were involved in the cause of wrong-patient procedures and contributed equally with surgical disciplines to adverse outcome related to wrong-site occurrences.

Conclusions: These data reveal a persisting high frequency of surgical “never events.” Strict adherence to the Universal Protocol must be expanded to nonsurgical specialties to promote a zero-tolerance philosophy for these preventable incidents.



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12 de agosto de 2011

Artigo: Main Concerns of Patients Regarding the Most Common Complications in the Post-Anesthetic Care Unit



Eduardo Toshiyuki Moro, TSA, M.D., Renato César Senne Godoy, M.D., Alexandre Palmeira Goulart, M.D., Leopoldo Muniz, M.D., Norma Sueli Pinheiro Modolo, M.D.


Revista Brasileira de Anestesiologia
Vol. 59, No 6, Novembro-Dezembro, 2009

INTRODUCTION

Preoperative anxiety is frequently associated with anticipation of anesthesia- or surgery-related damages. Severe complications that can be attributed to anesthesia such as death are rare. On the other hand, “minor” events such as pain, nausea, or vomiting have assumed a fundamental role in the determination of the quality provided by the Anesthesiology service1.

When postoperative fears are analyzed regarding low morbidity events that should be avoided the most, anesthesiologists have not always been capable to determine the priorities of the patients2. Thus, successful treatment of postoperative pain, for example, is not necessarily related with higher satisfaction with anesthesia, since the consequences of pain treatment, such as nausea and vomiting, should be considered.

In a study undertaken in the United States, Macario et al.3 evaluated the opinion of patients on the subject. Possible undesirable effects in the immediate postoperative period based on data from the literature (MEDLINE between 1986 and 1997) were listed. Since the list generated by this search was extensive, the authors decided to select the nine most frequent events, besides a tenth item described as “normal” (without any undesirable effects) to evaluate the reliability of the answers, since understanding of the questionnaire by the patients interviewed presupposed that the “normal” item would always be classified as “the least undesirable” or the “most desirable” (Chart I).

However, the study population was composed mainly by individuals with high socio-economical and cultural level, which might not represent the reality of health services in regions where social indicators usually show a higher inequality rate. The objectives of the present study included:
1) to evaluate the main concerns of patients regarding the post-anesthetic period and to compare them with those observed by Macario et al.3; and 
2) to test the hypothesis that the most undesirable effects, according to the opinion of the patients interviewed, could be influenced by demographic characteristics like educational level and family income.

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9 de agosto de 2011

Artigo: Staffing the Operating Room Suite: Perspectives from Europe and North America on the Role of Different Anesthesia Personnel


Christoph B. Egger Halbeis, MD, DEAA, MBA
Armin Schubert, MD, MBA

Anesthesiology Clin 26 (2008) 637–663

A spectrum of anesthesia personnel is needed to staff operating rooms. The training, professional and technical roles, and workforce contribution of anesthesiologists, anesthetists, and various support personnel in Europe and the United States are described. Current and future factors influencing the relationship between provider availability, use, and demand differ across the Atlantic and within Europe.

CURRENT TYPES AND ROLES OF ANESTHESIA PROVIDERS

Who Practices Anesthesia?
Anesthesia providers can be subdivided into physicians and nonphysicians. Physician anesthesia providers are called "anesthesiologist" and "anaesthetist" in North America and the United Kingdom, respectively. The term "anesthesiologist" is used throughout this article.


Anesthesiologist training in North America and Europe
In the United States, anesthesiologists are overwhelmingly trained in residency programs accredited by the Residency Review Committee of the Accreditation Council for Graduate Medical Education (ACGME). A residency in anesthesiology requires 4 years of training with rotations in anesthesia; critical care; pain management; perioperative care; and selected areas of medicine, including internship. Upon completing training, anesthesiologists are certified by the American Board of Anesthesiology (ABA). Some anesthesiologists pursue advanced training in various anesthesia subspecialties, pain management, or critical care fellowships.

There are residency training programs other than those governed by ACGME and the ABA. The American Osteopathic Association (AOA), through its agency the Bureau of Osteopathic Specialists, accredits osteopathic anesthesiology residency training programs. Twenty osteopathic anesthesiology trainees were ‘‘projected’’ to complete residency in 2005.1 Since 2002, the total number of approved osteopathic anesthesiology positions has increased 50% by 23 positions. The osteopathic output, however, remains at only less than2%of the total annual training output of anesthesiologists. Aside from the ABA and the American Osteopathic Board of Anesthesiology there are a few other specialty boards that ‘‘board certify’’ for anesthesia: the American Dental Board of Anesthesiology through the American Dental Society of Anesthesiology and the National Board of Anesthesiology. Dental anesthesiology residency programs are generally 2-year programs that commence after graduation from dental school. Presently, there are seven active programs across the United States. Approximately 10 to 15 residents graduate from all dental programs each year. Dental anesthesiologists usually restrict their practice to dental surgical patients and do not contribute materially to the anesthesia workforce.

In Canada, anesthesiology is a physician-based service. Entry into anesthetic practice occurs by one of four routes: (1) graduates of the 16 Royal College of Physicians and Surgeons of Canada; (2) nonspecialist anesthesiologists, physicians having completed but not graduated from the anesthesia training; (3) internationally trained anesthesiologists; for this subpopulation, significant entry barriers exist, which are controlled by each provincial licensing authority; and (4) family physicians providing anesthesia services in 4% to 20% of cases, depending on the province.

In Europe, every major country offers a physician anesthesia postgraduate training program (residency). On average, these training programs do not match those in the United States, where residency programs are strictly regulated and monitored by a central agency. European physician postgraduate training is typically less structured. In many countries, to become board-certified, residents are required to work a certain number of years, to pass the national board-examination, and to achieve a required list of anesthetic procedures and mandatory courses. Each European country has its own laws regarding physician licensing.

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3 de agosto de 2011

Artigo recomendado: Sedation and anesthesia in GI endoscopy

David R. Lichtenstein, MD; Sanjay Jagannath, MD; Todd H. Baron, MD, Chair; Michelle A. Anderson, MD; Subhas Banerjee, MD; Jason A. Dominitz, MD, MHS; Robert D. Fanelli, MD, SAGES Representative; S. Ian Gan, MD; M. Edwyn Harrison, MD; Steven O. Ikenberry, MD; Bo Shen, MD; Leslie Stewart, SGNA Representative; Khalid Khan, MD, NAPSGHAN Representative; John J. Vargo, MD, MPH

Gastroenterology 2007;133:675-501 (DOI:10.1053)

BACKGROUND

Sedation may be defined as a drug-induced depression in the level of consciousness. The purpose of sedation and analgesia is to relieve patient anxiety and discomfort, improve the outcome of the examination, and diminish the patient’s memory of the event. Practice guidelines have been put forth by the American Society of Anesthesiologists (ASA) Committee for Sedation and Analgesia by Non-Anesthesiologists, and approved by the ASGE.1,2 

Four stages of sedation have been described, ranging from minimal to moderate, deep, and general anesthesia (Table 2). In general, most endoscopic procedures are performed with the patient under moderate sedation, a practice that was formerly referred to as "conscious sedation."

At the level of moderate sedation, the patient, while maintaining ventilatory and cardiovascular function, is able to make purposeful responses to verbal or tactile stimulation. In contrast, a patient undergoing deep sedation cannot be easily aroused but may still respond purposefully to repeated or painful stimulation. Airway support may be required for deep sedation. At the level of general anesthesia, the patient is unarousable to painful stimuli, and cardiovascular function may be impaired.

The level of sedation should be titrated to achieve a safe, comfortable, and technically successful endoscopic procedure. Knowledge of the pharmacologic profiles of sedative agents is necessary to maximize the likelihood that the desired level of sedation is targeted accurately. Individuals differ in their response to sedation, so patients may require different levels of sedation for the same procedure and patients may attain varying levels of sedation during a single procedure. Therefore, practitioners should possess the skills necessary to resuscitate or rescue a patient whose level of sedation is deeper than initially intended. This statement will evaluate the strength of evidence in the medical literature to provide guidelines for the use of sedation and anesthesia during GI endoscopic procedures and is an update of 3 previous ASGE documents.2-4

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1 de agosto de 2011

De 1 a 3 de setembro: 1º Congresso Meridional da Qualidade em Saúde



Local: Hotel Golden Tulip / Vitória-ES
Publico Alvo: Profissionais da Área da Saúde (médicos, enfermeiros, fisioterapeutas, psicológos, dentistas, nutricionista, farmaceuticos, administratores hospitalares e estudantes das áreas afins)


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