The clinical safety of patients: understanding the problem

An article in the Colombian magazine COLOMBIA MEDICA 2005 touches the issue of patient safety with a good introduction to understand the problem. The clinical safety of patients: understanding the problem Astolfo Franco, MD Assistant Professor, School of Public Health, Faculty of Health, Universidad del Valle, Cali.Published March 15, 2005 Unexpected deaths of patients in hospitals across the United States of America (USA) in the mid-1990s, as the Libby Zion case a girl of 18 who died a few hours after his admission to one of the health care centers in New York as a result of a drug interaction between an antidepressant he was taking and a narcotic analgesic that he was given at the hospital, or that of Betsy Lehman died in 1994 at the Dana Farber Cancer Institute from an overdose of cyclophosphamide for transplantation bone marrow, the government took the Clinton administration ordered the creation of a committee to investigate the quality of health care in this pa s1.This mandate has continued during the Bush administration and its need has been reinforced by the report as the most recent cases of Josie King, a 2-year-old who died in the Johns Hopkins University Hospital from an overdose of morphine when was in a convalescent phase of burns and Jessica Santillan, a 17-year-old who, during a double heart-lung transplant, he transfused the wrong blood type which caused acute rejection and secondary brain death This Committee and many others have the following objectives that are worth highlighting: Establish a national fund to create national leadership in patient safety and a research agenda in areas related foresight. Identify and learn from mistakes in clinical care occurred through a mandatory reporting system. Create safe systems in health institutions and implement safe practices. Create standards expected in a consensus among professionals, insurers and providers. The first major product of this committee appeared in early 2000 when the Institute of Medicine of the United States reported the final results of an investigation conducted on medical errors in 30.195 patients in hospitalaria4 form. The report called “To err is human” concluded that between 44,000 to 98,000 people die annually in hospitals in this country as a result of errors that occur in the processes of care. Of these deaths, 7,000 occur specifically as a result of errors in the medication administration process. These numbers placed immediately to the medical error mortality in the USA as the eighth leading cause, even over mortality caused by traffic accidents, breast cancer or AIDS.These figures have been questioned by some authors who report that the report did not conclude that all deaths are by medical error, but the clinical status of patients was so severe that just going to die. In March 2002 the World Health Organization (WHO) at its 55th World Assembly reported very high rates of adverse events for various developed countries of between 3.2 and 16.6 6 corroborating the major problem existing in the global arena. If you add to the thousands of people as a result of the error did not die but were left with a temporary or permanent disability, the problem takes almost epidemic dimensions, for which WHO launched the Global Alliance for Security Paciente7 Clinic.

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