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Error En Medicina
- 1. Dr. Puede devolverme el termómetro rectal
- 2. ERRAR ES HUMANO… PERO RECONOCERLO ES MAS
- 3. Peligrosos (>1/1000) Regulados Ultra-seguros (<1/100K) Cuidados de salud Jumping de puentes Montañismo Manejar Manufactura Química Vuelos de Charter Airolineas Ferrocarries Europeoss Plantas Nucleares Número de casos por cada víctima Total vidas pedidas por años
- 4. Errores Medicos EA Eventos adversos prevenibles
- 5. • 1.2 Trillon dólares • 12-14% del PBI • Afecta a todos los ciudadanos CUIDADOS DE SALUD EN USA
- 11. Reporting of Adverse Events Lucian L. Leape, M.D. HOME | SEARCH | CURRENT ISSUE | PAST ISSUES | COLLECTIONS | HELP at Your Institution | FAQ Pr evious Volume 347:1633-1638 November 14, 2002 Number 20
- 16. ERROR EN MEDICINA DE URGENCIAS
- 17. (Activo/Human0) Deslices Equívocos Omisiones EFECTOS ADVERSOS PrevenIbles Eventos Adversos Prevenibles Negligencia ERROR Desviación del plan previsto Plan Incorrecto
- 21. EDUCACION: CONCEPTO CLAVE Yo escuché, Me olvidé Ya veo, me acuerdo que.. Lo hice, ya entendí Lao-Tsu
- 22. En los últimos 50 años en la humanidad los mayores avances han sido en la medicina y en las ciencias de la informática. Ellos están convergiendo!
- 23. Modelo del “queso suizo” como las defensa, barreras, y cuidados pueden penetrados por la trayectoria de un accidente
- 24. ALGUNOS PROBLEMAS NO BIOÉTICOS DE TRASPLANTES. Transplante de pelo
- 26. Sources- Mills et al. (1977), Brennan et al. (1991), IOM (1999). Todas las Hospitalizaciones Lesiones negligentes ( 1-2%)
- 27. Estudio del California Medical Insurance Feasibility Estudio del Harvard Medical Practice 17% 28% Eventos adversos Eventos adversos
- 28. 10% 13% Todas las lesiones Negligentes Todas las lesiones Negligentes Estudio del California Medical Insurance Feasibility Estudio del Harvard Medical Practice
- 29. 1000 280 36 Todas las lesiones Todas las lesiones negligentes Expedientes de reclamo 13% de lesiones por Negligencia que terminaron en denuncia
- 30. 1000 280 6 30 Todas las lesiones Todas las lesiones negligentes Expedientes de reclamo 2% de lesiones por Negligencia que terminaron en denuncia
- 31. 27,179 eventos adversos debidos a negligencia 26,764 sin denuncias por malpraxis (98%) 415 denuncias por malpraxis (2%) 14,180 con fuerte evidencia de negligencia 12,858 sin secuelas 7462 con secuelas < 6 meses (58%) 5396 con secuelas ≥ 6 meses (42%) Fuente – Localio, 1991
- 32. Source – Hickson, 2002 Physician Characteristic Total Physicians (N = 645) Mean Number of Complaints Surgeons (N = 219) No lawsuits (N = 102) 6.1 1 lawsuit (N = 82) 16.7 2 or more lawsuits (N = 35) 35.1 Non-surgeons (N = 426) No lawsuits (N = 361) 4.7 1 lawsuit (N = 57) 9.2 2 or more lawsuits (N = 8) 4.6
- 33. % de quejas % de médicos Fuente – Hickson, 2002
- 34. EDUCACION MEDICA Cognitiva Sensorial Cinco sentidos+ sentido comun Motora*
- 35. El Radio no tiene futuro. LORD KELVIN Matemático y físico Escocés, Primer presidente de la Royal Society, 1897
- 36. Todo lo que podría haber sido inventado ha sido inventado. CHARLES H. DUELL U.S. commissioner of patents, 1899
- 37. No hay razón para que cada medico no tenga una computadora en su casa KENNETH OLSEN president and founder of Digital Equipment Corp., 1977
- 41. Habilidad motora percepción Conocimiento análisis juzgamiento Haciendo una educación medica correcta usando el poder de la simulación se hace mejor Un sistema de enseñanza-aprendizaje ©2000 David Williamson Shaffer Ideas en la acción Tutoraje breadth Ideas acerca de la acción
- 42. La mejor manera de predecir el futuro es inventándolo. Alan Kay
- 44. IMPEDIMENTOS • Tradición • Reglas del Servicio • Financiamiento • ¿Eficacia?
- 48. Weingart, SN. “Epidemiology of Medical Error.” BMJ 2000;320, from 1995 Quality in Australian Health Care Study.
- 59. Error Causas mas Proxima Factores Sistema Identificando Causas del error: Arbol de problemas
- 66. Señoriíta por favor ponga en el monitor el icono que dice “Que hacer en casos complicados “
- 72. HOSPITALIZACIONES 3,3% Eventos Adversos Mapa de la Adversidad Médica (Harvard Medical Practice Study, Nueva York 1984) Resultado de análisis de 30.000 pacientes hospitalizados en 51 hospitales de NY Evento Adverso: Daño resultado de una intervención médica y no de la enfermedad o condición subyacente del paciente
- 73. Hospitalizaciones Mapa de la Adversidad Médica (Harvard Medical Practice Study, Nueva York 1984 ) El 58% de los eventos adversos son evitables El 2,6% del total de eventos adversos resultan en muerte EVENTOS ADVERSOS 58% por error 27,6% por negligencia
- 76. Arizona US$ 3 mill 1998 Kentucky US$ 13 mill 1998 Mississippi US$ 100 mill 2002 Nevada US$ 6 mill US$ 5,4 mill US$ 4,6 mill 2001 2001 2001 Carolina del Norte US$ 23,5 mill US$ 4,5 mill US$ 8,1 mill 1997 2001 2001 Pennsylvania US$ 100 mill 1999 Washington US$ 3,8 mill 1998
- 77. LA CRISIS DE LA RESPONSABILIDAD MÉDICA EN LOS ESTADOS UNIDOS
Notas del editor
- Another way to look at the problem was described by Lucian Leape, who has been responsible for drawing much of the current attention to the problem.
- This Venn diagram shows the relationships. A few examples would be Medical Error: A patient says they have an allergy to penicillin, the doctor gives it to them. They take the medication but have no ill effects. Adverse Event: A patient develops a blood clot after a surgery despite being placed on anticoagulants (blood thinners) PAE: A doctor does not check an EKG and misdiagnosis a patient with an ulcer who has actually had a heart attack
- However, this is still an over estimation because this assumes that all claims involve a negligent injury
- However, this is still an over estimation because this assumes that all claims involve a negligent injury
- Australian study of 14,179 admissions looking at rates of adverse effects in 28 hospitals. Adjusted for “risk category”(4). Increase in number, number preventable, number resulting in permanent disability 4 times as many adverse events; twice as many preventable events Reasons? More comorbid conditions, less reserve, (less attentiveness?)
- Average ICU patient has approx. 30 medications; may have twice that many. (Cullen DJ 2001, report of ADE Prevention Study) 1.7 mistakes/day: hundreds of interventions/day (99% proficiency), but still could kill patient Surgical AEs: most obvious (wound dehiscence, infection, wrong leg amputations); “Hotbeds of human error,” (Bogner 1994, Human Error in Medicine) ERs: Similar to ICUs and ORs in environment--rapidly changing, high tech, time stress (Leape L in Bogner, Human Error in Medicine ) Medical Wards: Second only to MICU in number of AEs; more than SICU or surgical wards (ADE Prevention Study) Outpatients: Not much data; Studies have shown that a large percentage of admissions (5-36%)to hospitals are due to iatrogenic injury and one study found 18% of patients who had drugs prescribed had adverse reactions. (from Weingart 2000)
- So, talking about barriers to identifying medical errors…. As I mentioned before, errors are difficult to identify because people don’t want to admit an error, not all errors cause injury. Use of benadryl, naloxone, high serum drug levels, leukopenia, phytonadione, antidiarrheals.
- Traditional approach to error in medicine
- Root Cause Analysis: Pioneered by aviation/nuclear power generation. Process for “getting to the root of the problem.” Goal: redesign organization and processes for risk reduction (examples: CPOE to avoid dosage errors, name problems) Systems: “every system is perfectly designed to produce exactly the result it gets.“ AEs are built into systems. If you don’t change the underlying conditions that set up this error, the error will reproduce itself elsewhere, perhaps by someone else or manifested in a different way. Goal: Look for common causes of errors, identify system problems and potential improvements, action plan, measurement strategy
- Like health care, high technology, high risk, tightly coupled (closely interrelated efforts). ASRS: Established by FAA 1975. Confidential error reporting. Greatly increased error reporting (Joint Commission, Sentinel Events chapter) Redundancy, buffers: errors happen, reduce risks Checklists: Pilots, mechanics, flight attendants have checklists before take-off. Reliance on human memory causes errors. Nuclear Power: 3 Mile Island NASA: Challenger
- Enormously important report; numbers somewhat contraversial: preventable AEs and deaths not well defined 8th leading cause: More deaths/year in the U.S. than MVAs, breast cancer or AIDS “ Tip of the Iceberg” Errors are difficult to study because more AEs than injuries (underreporting) This report created a huge uproar in the popular press
- En EU solo el 28% de la prima va a pacientes Un estudio hecho por el Harvard Medical Practice Study III publicadop en el new England Joyurnal of Medicine en 1991 concluyó que: “la evidenmcia es cada día mayor de que hay una pobre correlación entre daños causados por negligencia médica y litigios por malpraxis”.