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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Maria Cristina Molina disse...

Pablo, verdadeiramente assustador! Se possivel, mande o artigo full-text para mim! Obrigada! cristinamolinaanest@bol.com.br

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