26 de outubro de 2011

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


J Am Med Inform Assoc. 2002; 9(Nov-Dec suppl):S58–S63. DOI 10.1197/jamia.M1229.

A b s t r a c t:  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.

Caso queira, deixe seu e-mail nos comentários abaixo desta postagem ou solicite pelo e-mail anestesiasegura@sma.com.br e enviaremos o artigo completo.

20 de outubro de 2011

2º Simpósio Interdisciplinar de Segurança do Paciente (SISEPA) - USP

Não percam!  Será no dia 27/10/2011 no Centro de Convenções Rebouças em São Paulo SP.

Texto Recomendado: General Anesthesia — Minding the Mind during Surgery

Gregory Crosby, M.D.

Editorials N Engl J Med 365;7 nejm.660 org August 18, 2011

William Morton’s demonstration of the use of ether in 1846 was powerful in part because the patient had no memory of the procedure; nowadays, patients expect to have amnesia with general anesthesia. But conscious awareness — the ability to remember and explicitly recall events that transpire during surgery — still occurs on occasion, sometimes with devastating psychological consequences. The easy explanation is that awareness is due to underdosing of the anesthetic agent. This explanation provides a sense of control and a ready fix (administer more anesthesia) but conveniently overlooks a secret: the state of consciousness is typically not monitored directly during general anesthesia. There simply is no accepted way to do it.

13 de outubro de 2011

Segurança dos pacientes, profissionais e organizações: um novo padrão de assistência à saúde

Patient, professional, and organization safety: a new Healthcare Standard

RAS _ Vol. 8, No 33 – Out-Dez, 2006 153

Antonio Quinto Neto - Médico, Mestre em Administração, especialista em avaliação de sistemas e serviços de saúde, docente de vários cursos de pós-graduação em gestão de saúde, Diretor Superintendente do Hospital Banco de Olhos de Porto Alegre, RS.


O autor tece considerações sobre o conceito de segurança do paciente e suas implicações para os pacientes, profissionais e organizações. Destaca a importância de substituir a cultura da culpa e castigo pela cultura da aprendizagem a partir da identificação e análise das falhas e acidentes.

Apresenta algumas medidas de segurança já disponíveis e dá ênfase à aplicação do protocolo universal que previne, no caso das cirurgias/procedimentos invasivos, local errado, cirurgia/procedimento errado e paciente errado. Menciona a acreditação de organizações de saúde como uma estratégia global de redução de risco para os clientes/pacientes.

Caso queira, deixe seu e-mail nos comentários abaixo desta postagem ou solicite pelo e-mail anestesiasegura@sma.com.br e lhe enviaremos o artigo completo.


5 de outubro de 2011

2º Simpósio Interdisciplinar de Segurança do Paciente (SISEPA) - FMUSP

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

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.

Caso queira, deixe seu e-mail nos comentários abaixo desta postagem ou solicite pelo e-mail anestesiasegura@sma.com.br e lhe enviaremos o artigo completo.

Artigo: Accidents by ABO incompatibility and other main complications related to blood transfusion in surgical patients

Data from the French national survey on anaesthesia-related deaths

Dan Benhamou, André Lienhart, Yves Auroy, Françoise Péquignot, Eric Jougla

Transfusion clinique et biologique 12 (2005) 389–390

Blood red cell transfusion often occurs in the perioperative setting and is a frequently performed activity in routine anaesthetic practice. Blood transfusion (including any technique of autologous blood transfusion is performed in nearly 3% of all surgical procedures in France, representing more than 200,000 transfusion procedures each year [1]. Because homologous blood transfusion is performed alone or is associated with any other technique of autologous blood salvage in 48% of cases (i.e. 107,000 patients) and because a mean of three units of red blood cells is used in each patient, it has been estimated that 295,000 packs of red cells are transfused in this country each year. Nearly 50% of these blood transfusion procedures are done during orthopaedic surgery, mainly total hip or knee replacement but one third of the procedures during which blood transfusion is used are emergency procedures [1] and this may have a link with the risk of errors (see below). Along with this, it should be noted that incidents are more often recorded in hospitals in which a small blood bank is used only for emergency situations than in large institutions in which blood transfusion is a routine activity and is used night and day for a large number of patients [2].

Data collected during a national French survey performed in 1997–1998 were aimed at assessing anaesthetic activity but recorded also several indicators reflecting transfusion activities in surgical patients. However, only intraoperative (and recovery room) activities were recorded. As it is well known that nearly 50% of perioperative blood transfusion episodes occur in the first postoperative week [3], it can be estimated that blood transfusion associated with surgical procedures represents more than 500,000 packed red cell units each year in France. These numbers explain why anaesthetists have long been interested in this activity and why the French Society of Anaesthesia and Intensive Care (SFAR) has been involved in (and sometimes has led) many expert conferences on blood transfusion.

Caso queira, deixe seu e-mail nos comentários abaixo desta postagem ou solicite pelo e-mail anestesiasegura@sma.com.br e lhe enviaremos o artigo completo.

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