Learning from Error (fragmento)
Summary
TLDREl script del video destaca la importancia de la seguridad del paciente en el Servicio Nacional de Salud del Reino Unido, revelando que el error médico y el cuidado inseguro son más comunes de lo que se pensaba. Se explora el fenómeno del error de inyección intraespinal, que puede causar parálisis o incluso la muerte. A través del análisis de incidentes y la identificación de 'trampas de error', se busca evitar futuras ocurrencias y fortalecer los sistemas para hacer que la atención médica sea más segura.
Takeaways
- 🏥 El Servicio Nacional de Salud en el Reino Unido fue uno de los primeros sistemas de atención médica en dar prioridad a la seguridad del paciente.
- 🔍 La frecuencia de errores médicos e atención insegura es mucho más alta de lo que se había reconocido anteriormente, afectando a aproximadamente a 1 de cada 10 pacientes hospitalizados.
- 💉 El error de inyección intraespinal es un fenómeno peligroso en el que un medicamento destinado a ser administrado intravenosamente se inyecta erróneamente en la médula espinal.
- 📊 Al analizar incidentes de muerte, se identifican errores y debilidades en el sistema que provocan atención médica insegura.
- 🌐 La Alianza Mundial para la Seguridad del Paciente busca hacer disponibles las experiencias del Reino Unido a nivel mundial para prevenir errores similares.
- 📚 El aprendizaje y la generalización de experiencias particulares pueden ayudar a fortalecer los sistemas y reducir el impacto de los errores en el futuro.
- 🤝 La colaboración y el apoyo entre profesionales de la salud son fundamentales para gestionar situaciones imprevistas y mantener la seguridad del paciente.
- 📝 La importancia de tener registros precisos y actualizados, como los números de hospital y las fechas de nacimiento de los pacientes, para evitar confusiones durante los procedimientos médicos.
- 🚫 La necesidad de evitar la administración de medicamentos incorrectos, como vincristina en lugar de metotrexato, que puede tener consecuencias letales.
- 🤔 La reflexión sobre la responsabilidad en casos de errores médicos, considerando que a menudo son el resultado de una serie de eventos y no solo de una acción individual.
- 🔑 La importancia de revisar casos de errores sin buscar culpables, sino para comprender los riesgos y mejorar la seguridad en la atención médica.
Q & A
¿Qué es el Servicio Nacional de Salud (NHS) y por qué es importante mencionarlo en el guion?
-El Servicio Nacional de Salud (NHS) es un sistema de atención médica público en el Reino Unido, uno de los primeros sistemas de atención médica en el mundo que dio prioridad a la seguridad del paciente. Es importante mencionarlo porque el guion discute los errores médicos y cómo el NHS ha trabajado para mejorar la seguridad del paciente.
¿Cuál es la frecuencia de errores médicos en el NHS según el guion?
-Según el guion, aproximadamente 1 de cada 10 pacientes hospitalizados sufren algún tipo de error médico.
¿Qué es la inyección intraespinal errónea y cómo afecta a los pacientes?
-La inyección intraespinal errónea es un fenómeno en el cual un medicamento destinado para uso intravenoso se administra equivocadamente en la médula espinal. Esto puede provocar parálisis y, en algunos casos, la muerte del paciente.
¿Cuál es el término utilizado para describir situaciones en las que los errores ocurren de manera similar y por razones comunes?
-Se utiliza el término 'error trap' para describir estas situaciones.
¿Qué es la Alianza Mundial para la Seguridad del Paciente y cómo se relaciona con el guion?
-La Alianza Mundial para la Seguridad del Paciente es una organización que busca hacer disponibles la experiencia del NHS en todo el mundo. El guion muestra cómo esta organización puede ayudar a prevenir errores médicos similares a nivel mundial.
¿Qué es la responsabilidad del personal médico y de apoyo en la prevención de errores médicos según el guion?
-El personal médico y de apoyo tienen la responsabilidad de analizar y aprender de los errores pasados para prevenirlos en el futuro, fortaleciendo los sistemas y reduciendo el impacto de los errores en la atención médica.
¿Por qué es importante no culpar a los individuos involucrados en errores médicos?
-Es importante no culpar a los individuos para no llevar los problemas al subterfugio y para fomentar una comprensión honesta y extensa de los riesgos, lo que permitirá abordar estos riesgos y garantizar una atención médica segura para los pacientes futuros.
¿Qué ejemplo de error catastrófico se presenta en el guion y cómo afecta a un paciente?
-El guion presenta el ejemplo de un error catastrófico en el que se inyecta vincristina en la médula espinal de un paciente en lugar de en la sangre. Este error lleva a una lesión grave al paciente.
¿Qué es la importancia de revisar casos como el presentado en el guion sin culpar a las personas involucradas?
-La revisión de casos como este sin culpar a las personas involucradas es importante para entender los factores que contribuyeron al error y para identificar las medidas preventivas necesarias para evitar futuras tragedias.
¿Cuáles son algunos factores que contribuyeron al error presentado en el guion?
-Algunos factores que contribuyeron al error incluyeron la falta de verificación de la prescripción, la falta de comunicación entre el personal médico y de apoyo, y la presión por realizar procedimientos en un horario ajustado.
¿Cómo se puede mejorar la seguridad del paciente en el futuro según el guion?
-Según el guion, se puede mejorar la seguridad del paciente al analizar y aprender de los errores pasados, fortaleciendo los sistemas de atención médica y evitando la repetición de errores similares.
Outlines
😨 Error Médico Grave
El primer párrafo describe el sistema de salud del Reino Unido y su enfoque en la seguridad del paciente. Se menciona que los errores médicos y el cuidado inseguro son más comunes de lo que se pensaba anteriormente, con una frecuencia de 1 en 10 pacientes hospitalizados afectados por algún tipo de error. Se analiza en profundidad el fenómeno del error de inyección intraespinal, donde un medicamento destinado a ser administrado intravenosamente se inyecta erróneamente en la médula espinal, lo que puede llevar a parálisis y muerte. Se discuten cerca de 50 incidentes registrados a nivel mundial y se sugiere que hay muchos más que no han sido registrados. Se destaca la importancia de analizar estos errores para prevenirlos en el futuro y se presenta el filme de la Alianza Mundial para la Seguridad del Paciente, que busca compartir la experiencia del Reino Unido a nivel mundial.
🚑 Atención y Coordinación en el Servicio de Salud
El segundo párrafo sigue la rutina caótica y las interacciones entre el personal médico en un hospital, incluyendo la coordinación de procedimientos médicos y la gestión de emergencias personales. Se discuten las dificultades de la planificación de procedimientos médicos para pacientes como Jane Hughes, quien tiene varias cirugías programadas en un solo día debido a compromisos laborales. Se menciona una serie de interrupciones y cambios de plan, como el retraso de Hughes debido a un accidente en la autopista y la situación personal de un miembro del personal que debe atender a un familiar con un infarto. La sección termina con la preparación para la llegada de Hughes y la toma de decisiones sobre la administración de medicamentos.
🤔 Confusión y Preparación para un Procedimiento Médico
El tercer párrafo sigue la llegada de Jane Hughes al hospital y las acciones del personal médico para prepararse para su procedimiento. Se destaca la interacción entre los médicos y el personal de enfermería, así como la preocupación de Hughes por su hijo después de un incidente en el camino al hospital. Se menciona la llegada de Dr. Robinson para ayudar con el procedimiento y se describe la preparación del Dr. Campbell para recibir a Hughes. Se destaca la importancia de revisar los resultados de sangre y el consentimiento del paciente antes de proceder con el tratamiento.
😱 Error de Administración de Medicamentos con Consecuencias Fatales
El cuarto párrafo narra un trágico error médico donde se inyecta incorrectamente un medicamento en la médula espinal de un paciente. Se describe la confusión y la prisa en el proceso de preparación para el procedimiento, lo que lleva a una serie de malentendidos y omisiones. El error se produce cuando se inyecta vincristina en lugar de metotrexato, lo que resulta en daños graves y potencialmente letales para la paciente. Se sugiere que este tipo de error puede ser evitado con un enfoque más cuidadoso y una mejor comunicación entre el personal médico.
🔍 Análisis de un Error Médico para Prevenir Futuros Accidentes
El último párrafo se enfoca en la importancia del análisis de errores médicos para prevenir futuros accidentes. Se argumenta que, en lugar de culpar a individuos por errores, es necesario examinar los sistemas y procesos que podrían haber contribuido al error. Se enfatiza la necesidad de una revisión cuidadosa de casos como el presentado en el filme, para identificar y abordar los riesgos subyacentes y mejorar la seguridad del paciente en el futuro.
Mindmap
Keywords
💡National Health Service
💡seguridad del paciente
💡error médico
💡inyección intraespinal
💡error de sistema
💡World Alliance for Patient Safety
💡error trap
💡fortalecimiento de sistemas
💡responsabilidad
💡revisión de casos
Highlights
The National Health Service in the UK prioritizes patient safety and has recognized the higher frequency of medical errors than previously realized.
Approximately 1 in every 10 patients admitted to hospital suffer from some form of medical error.
Intrathecal injection error, where a drug intended for intravenous use is mistakenly given into the spine, can lead to paralysis or death.
Worldwide, there are around 50 recorded incidents of intrathecal injection error, with potentially many more unrecorded.
The concept of 'error trap' is introduced, where common causes may lead to similar errors in different circumstances.
The World Alliance for Patient Safety aims to share the UK's experience to improve global healthcare safety.
The importance of analyzing errors without blaming individuals to prevent future occurrences is emphasized.
The film discusses the role of strengthening systems to reduce the impact of errors in healthcare.
A scenario involving Jane Hughes, who is scheduled for two procedures on the same day, is presented to illustrate the complexities of medical care.
Communication errors and misunderstandings among staff are highlighted as potential contributors to medical mistakes.
The transcript describes a situation where a patient's delay in arrival impacts the workflow and creates pressure on staff.
The role of personal recommendations in the hiring of medical staff, and the trust placed in their competence, is discussed.
The impact of personal emergencies on healthcare professionals and their ability to provide care is portrayed.
The film presents a case where a doctor covering for another mistakenly administers the wrong medication, leading to a critical error.
The importance of checking and double-checking procedures to prevent medical errors is underscored.
The film concludes by emphasizing the need to review cases carefully to identify systemic factors contributing to errors.
The discussion encourages addressing risks to ensure the safe care of future patients rather than focusing solely on individual blame.
Transcripts
the National Health Service in the
United Kingdom was one of the first
healthcare systems in the world to give
priority to patient safety the work done
in the UK over the last few years has
involved taking account of the things
that go wrong in health care the
frequency of medical error and unsafe
care is much higher than we've realized
in the past something like 1 in every 10
patients admitted to hospital suffer
from some form of medical error it may
not always lead to serious harm but in
some cases sadly it leads to major
disability and even death one of the
incidents we've examined in depth is the
phenomenon of intrathecal injection
error this is where a drug intended for
use intravenously is given instead into
the spine mistakenly the patient then
experiences paralysis and even death
when we've analysed these incidents in
death we've spotted all sorts of errors
and weaknesses in the system which
provoke unsafe care to be given by
analysing these and by learning from
them we've tried to work out the ways in
which this error can be prevented in the
future they're around 50 recorded
incidents around the world of
intrathecal injection error many more
may not even have been recorded from the
incidents we're aware of so far we know
that they often occur in similar
circumstances to different people at
different times and even in different
places experts call this situation an
error trap there's a common cause and
probably a common solution with this
film the World Alliance for patient
safety is making the experience of the
United Kingdom available worldwide we
hope that by studying this scenario and
discussing it afterwards you'll be able
to see the many ways in which unsafe
systems can provoke unsafe care by
generalizing the experience of this
particular incident we hope that you'll
be able to see the ways in which
strengthening systems play a role in
reducing the impact of error this can
help make health care even safer in the
future
you
morning I thought to Livingston
yeah telephone oh thanks son excuse me
Duncan hello yeah it's gonna shot
pharmacy here yes it's about this is
Jane Hughes needs a Plex sake you sent
down only sent her VIN Christina I was
wondering if there'd be a mistake about
that
mrs. Hughes is having both her
procedures on the same day she's got a
pig workmansh in a couple of days time
and she can't get out yes but you see
he's signed a prescription I assume that
you'll be taking the full
responsibilities yes okay then look
Haleh prepared for this afternoon sorry
sister Lynch I'd like you to meet dr.
Campbell he's just joined us and he's
going to be working with me over the
next couple of weeks I have to say
Duncan you're going to be giving us some
much-needed support
I'd like to hear hello sister pleased to
meet you welcome to the unit thanks very
much by the way man mrs. Hughes would
already be on your list this morning for
her eye opinion which is also having her
intrathecal this afternoon she's got a
big meeting at work in a few days time
so we're going to try and fit her in for
both procedures today
I didn't order going back to work she's
only just started she's taking it easy
showing me a couple of days to begin
with right so Duncan your papers and NTN
number should be through in a day or so
but meanwhile welcome aboard thanks very
much ah this might be problem I'll take
you three girls now see you both later
okay boy dr. Livingstone before you go I
just wanted to be clear about the amount
of clinical work dr. Campbell will
actually be doing how much have we got
you'll take on virtually anything I
would if he's unsure about anything that
I'm always here to help so he's familiar
with the IT rules I would
I expect so he's very senior and he can
do just about anything I can but Fiona
he's not on the IT register yet is he no
but I've seen dr. Monroe about that
later and we sorted out then Oh Simon I
wanted a word so he's fine with any of
our procedures but he's here on the
personal recommendation of dr. Monroe's
sister so as far as I'm concerned if dr.
Monroe thinks he's competent I'm
prepared to go along with that now he'll
be acting as the specialist registrar
and I'm hoping that you and your staff
will give him every assistant course we
will write the Jane cutest intrathecal
that will still be under your care
wanted yes hi Abby it's Jane Hughes here
I'm late I'm stuck sister Jane huge just
phoned apparently there's been a really
nasty accident on the motorway and she's
caught in the tailback grater yeah she
said she's gonna be quite late at least
two hours what a day to be late look
Abby I'll be off shift by the time she
gets here I've got to leave a bit early
for a dentist appointment I'll put
everything in a notice but I'm going to
miss the handover so can you make sure
the sister Roberts knows what's
happening of course I get the nurse
ready for her
all right darling okay good boy
being a really good boy we'll be there
soon I'll be there as soon as I possibly
can
don't try to calm down it should only
take me half an hour at the most I'll
see you as soon as possible
Wow is everything okay not really sister
no actually that was my mother on the
phone my father's had a coronary I've
got to get over to the general oh I'm so
sorry yes obviously you must go thank
you
look dr. Campbell will cover for me
could you show him around and taking
through the notes when you get a chance
oh yeah I mean I haven't had a chance to
see the notes myself yet but uh I'll do
what I can
oh I'm sure we'll manage don't worry
just gonna be with your father
Thanks I'll call in later
yeah can you come up for me this
afternoon strong I'm sorry about the
late notice it's my father
I said an mi and I want to be with him
I'm sorry of course no problem
thank you my doll sister wants to go
over a few things I'm sure between you
and manage fine I'm sure
good luck thank you
dr. Robertson Simon is Fiona Livingston
the short notice my father's had a
coronary I've got to get over to the
gentleman I'm sorry okay excuse me I'm
dr. Campbell covering for dr. Livingston
today have you seen her sister anywhere
sister Roberts
yep there she has done there by the
nurse's station sister Roberts thanks
mate thank you just the rollers I'm dr.
Campbell covering for dr. Livingstone
today I understand she's arranged for
Nico to give us a hand this afternoon
dr. Simon Robinson is he here yet no
Abby has mrs. Hughes arrived yet please
no she's just called in she's about ten
minutes away it's you she's one of mine
about you're done to pharmacy for the
chemo thanks very much see you later
okay
when mrs. Hughes arrives
can we make sure that they eighths ready
for me yes thank you
hello hi just a moment mrs. Stephens you
know I'm covering for dr. Livingstone
I've come to pick up the chemotherapy
for mrs. Chang Hughes empathy called
methotrexate which is on the dr. Munro
all right dr. Campbell I'm Charlotte
green and she'll be performing the
procedure today we are will be here
right I'll just check the register just
procedure
well they should have been sort of that
with dr. Munro by name and I think that
dr. Livesey spoke to mr. Shah earlier on
okay then sorry about this take a seat
that's a look on the database it's
Campbell
Duncan Campbell I mean it should be that
there's not going to be I'm sorry I'm
just looking for time I thought oh yes
there you are sorry about this hello
pharmacy yes yes that's right and what's
the patient's name again
part sure that's fine be ready by Paul
this afternoon okay great bye
it seems his only just pick the list now
your patient would that be a Jane Hugo's
right I just take this as double for you
he'll be our doctor next rx-8 two
milligrams in two nails so doctors
beautiful note when I take this hello
pharmacy yes here's one focusing lunch
at the moment for took a message
what's don't feel that fine why now
where were we
Jane Hughes hospital number three to six
seven nine eight zero eight above 26
1274 match number V X forty seven two
nine four now if you could just sign
with
but my sweetie
hi Jane oh you must've had a nightmare
yeah she's into everything where are we
today at me well I'm not quite sure
what's happening today they're having a
few problems but I'm pretty sure we're
in beta right yes
it's this one look can I take your bike
oh thanks mrs. Hughes arrived yet yes
she's just sitting in that great would
you check this methotrexate can I borrow
your pen I've left mine in pharmacy let
me go thanks a lot
look would you put this in the fridge to
move why not go and deal with this
thanks a lot
hello sister Hana it's mrs. Susie
yeah yeah she's just checking in now
thanks for helping out I've left our
notes on the side and I'll be with you
in a minute
no problem
so how's George he's been bothered
actually got a terrible tantrum in the
car on the way here I don't mean we were
stuck bumper-to-bumper for hours it was
awful anyway he's dead now sir could you
pass me my Walkman loudly it's in my bag
I just do your pleasure they may get it
for you
hi oh hi Simon see you happy now nice
it's just come on Oh could you get James
woman that's not bad for me please so
what can I do for you
dr. Nicholson asked me to give you a
nice afternoon seems like she's got her
hands full sorry um mrs. Hughes isn't it
yes I'm dr. Robinson hi how are you
feeling pretty awful actually
I've been stuck in the car for hours I'm
so sorry told you all up all right mrs.
Hughes I'm dr. Campbell covering for
doctors at least in this afternoon hi
dr. Campbell I had a better father it's
awful
will you be all right I'm sure he's in
very capable hands you must be dr.
Robinson thanks very much for helping us
out to such short notice
no worries happy to help no mrs. Hughes
you understand what treatment you'll be
adding this afternoon yes right let's
have a look at mrs. Hughes blood results
then shall we
yeah but all that's fine and the consent
form yes observations all right right do
check the respondent please
right it's mrs. Jane here's hospital
number three to six seven nine eight
zero date of birth 26:12 74 if the need
is I presume not calm let's just honor
this
argh you look great look listen before
you do that would you just check the
local with me then I'll prep the skin
now you will feel just a little bit of
pressure here yeah
wonderful
that's great
anything important I'm not sure right
I've taken a message there you go
right so where who was it someone from
Edmund that's the third time today
all right I'm ready for the chemo night
Simon I'm sorry would you mind going and
picking up from the from the fridge I
think we've lost it's almost completely
math I think there's a problem on the
wall
thanks very much the live alright mrs.
Hughes won't be much longer now
okay meal I'm afraid Abby's gonna be a
while yeah I've just seen her rushing
around look we can't afford to waste any
more time we you'll just have to check
it with me is that okay okay fine
Jane Hughes Hospital number three to six
seven nine eight oh yeah Billy
twenty-six 1274 yeah
expiry date oh wait everything okay
Simon dr. Campbell yeah hello Einstein
fine I'm staying but a bit of a problem
on the ward yes I'm sorry
staff there shouldn't be too much longer
actually we're nearly finished here now
tell me is my an exciting patient
arrived yet yeah he's in the waiting
room I have explained where one in life
can you check his blood results they're
not my king coat Thanks ignore it
just ignore it you will thank dr.
Livingstone for me won't you is such a
help putting me in like this of course I
will it's not a problem
that okay vincristine two milligrams
into milk
okay that's it
got a plaster
well then sorry to hold you up you can't
have finished already
yeah well I've gotta make a trick sake
so what have you given her and someone
call dr. Monroe please
you
the film you've just seen provides a
shocking example of how a series of
errors can lead to catastrophic harm to
a patient the first question you might
like to ask is who was responsible for
this tragic outcome the most obvious
answer may be dr. Campbell he mistakenly
injected vincristine into the patient's
spine however I want you to consider a
far more critical question why did dr.
Campbell find himself in such a position
sitting in front of a patient with an
open spinal needle in their back
having been handed the incorrect and
potentially lethal drug in reality dr.
Campbell's error was the final act in a
chain of events each of which had it
been identified at the time may well
have prevented this tragic outcome it's
therefore important to carefully review
cases such as this as much as possible
we need to do this without blaming the
individuals involved that's not to say
that individuals should not be held
accountable for their actions however
although apportioning blame may be
emotionally satisfying it's likely to
drive problems underground and impede an
honest and far-reaching understanding of
the risks we need to address these risks
to ensure the safe care of future
patients let's return to the film and
identify some of the factors that played
a part in this error
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