Eventos adversos e não conformidades em imagiologia.

Abstract

In 2000, the Institute of Medicine's report, To Err Is Human: Building a Safer Health System, caught the public attention documenting the magnitude of the medical error problem and the inherent patient safety: medical errors cause between 44,000 and 98,000 deaths annually in the United States. Currently, there is a growing interest in risk management on the medical field, particularly in the management of adverse events. It has been mainly due to the commitment of the World Health Organization, that this field of research has gained increasing the attention it deserves. Medical imaging is one of the high risk fields for the occurrence of errors, especially due to the multiplicity of techniques, the several stakeholders and the complexity of the whole circuit that involves the conduct of studies. Many of the methods used to analyze patient safety were adapted from risk-management techniques in high-risk industries (e.g. chemical, nuclear power and aviation industry). It is recognized that we can learn more from our mistakes than from our successes and the reporting systems in these industries have provided a valuable contribution to error prevention and risk management techniques. At a minimum, adverse events reporting systems can help to identify hazards and risks, providing important information on the system aspects that should be improved. However, the accumulation of potentially relevant data contributes little to healthcare services improvement. It is crucial to apply models to identify the underlying system failures, the root causes, and enhance the sharing of knowledge and experience. In this paper, it is suggested a solution to reduce adverse events, by identifying and eliminating the root causes that are in their source. How the Eindhoven Classification Model was adapted and extended specifically for the Medical Imaging field is also presented. The proposed approach includes the root causes analysis and introduces incomplete information concepts through the use of logical-mathematical operators formally sustained. This model is the basis of the adverse event and near misses reporting and learning system that was developed for Medical Imaging and is implemented in two Portuguese healthcare institutions. The objectives, characteristics and function of this system are presented throughout this article.

Amatoxin-Containing Mushroom Poisonings: Species, Toxidromes, Treatments, and Outcomes

“…A retrospective analysis of 93 mushroom poisoning cases in Portugal over the reporting period of 1990 to 2008 attributed 63.4% of cases to amatoxin-containing mushrooms, with 11.8% of these resulting in fatalities. 12 A retrospective analysis of mushroom poisonings in Switzerland over the reporting period of 1995 to 2009 confirmed 32 cases of amatoxin-containing mushroom poisonings, with 5 fatalities. 13…”

Factors affecting the recurrence of medical errors in hospitals and the preventive strategies: a scoping review

“…Use of electronic systems : The findings of several studies have emphasized the importance of using electronic systems such as CPOE (Computerized Provider Order Entry) and barcode systems to prevent the recurrence of errors ( 14 , 19 , 21 , 23 , 28 , 32 , 46 ). The barcode system can reduce misdiagnosed drugs, prevent misidentification of the patient and misuse of time, and reduce missed and wrong dose errors ( 46 ).…”

“…Training campaigns with varied and specific topics in the field of patient safety have been very useful in reducing errors (for instance the campaign of "sign your site") due to the extent of these campaigns ( 20 , 32 , 35 ). In addition, using educational models such as the Potential Risk Assessment Model ( 26 ) and the Eidenhaven Classification Model ( 14 ) will improve learning from errors and reduce medical errors. Although RCA is used to provide solutions to prevent the recurrence of errors, it appears that this method cannot prevent errors from recurring ( 38 , 45 ).…”

“…In addition to preventing errors from recurring, the use of electronic systems ( 14 , 19 , 28 , 32 , 35 , 39 , 42 ) such as barcoding and CPOE, as well as electronic alarms, can be very useful, since they allow staff to focus on sensitive tasks with more ease and efficacy. In a study conducted to examine whether physicians’ use of electronic systems promotes patient satisfaction or blame for medical outcomes, it was found that using a decision support system was very effective in reducing blame after medical errors ( 49 ).…”

“…The Joint Patient Safety Group has introduced several patient safety goals to help healthcare providers create a safer environment for patients as well as themselves ( 13 ) . However, despite these efforts, the rate of medical errors leading to disability and significant mortality is high ( 14 ) . Moreover, we still encounter errors that have detailed guidelines dedicated to them and should not keep recurring.…”