A carregar...
Publicação
Erros e acidentes no bloco operatório : revisão do estado da arte
| Nome: | Descrição: | Tamanho: | Formato: | |
|---|---|---|---|---|
| 529.71 KB | Adobe PDF |
Autores
Orientador(es)
Resumo(s)
RESUMO - Os blocos operatórios têm uma prevalência alta de erros e acidentes. Estes vão desde as
interrupções do fluxo cirúrgico, a acidentes minor e eventos catastróficos. O autor revê as
áreas de actividade do bloco operatório em que os erros acontecem com mais frequência e
identifica os mecanismos e a origem mais comuns — factores humanos e de equipa, factores
organizacionais, a complexidade das tarefas, as influências do ambiente e o puro acaso.
Os erros típicos e os padrões de erros são revisitados tal como os mecanismos de ocorrência:
cirurgia errada, no doente errado, no órgão errado e no lado errado, corpos estranhos
deixados, infecção cirúrgica e trombose venosa — embolia pulmonar.
As relações mal estabelecidas entre o volume cirúrgico e a performance são discutidas,
bem como, as suas complicações.
A segurança dos doentes no bloco operatório é um tema actual que recebeu recentemente
grande atenção da OMS que o tomou mesmo como prioridade.
ABSTRACT - Operation theatres are the health care spots where error and accident prevalence is higher. Those adverse events span from surgical flow interruptions to minor accidents to catastrophic events. The author reviews the activity areas where errors most likely occur and identifies their major determinants and mechanisms — human factors, system factors, team factors, task complexity, ambiance and pure chance. Typical errors and error patterns are revisited, as well as their occurring mechanisms — wrong patient, wrong surgery, wrong organ, wrong side surgeries, unwanted foreign bodies left, surgical infection and deep venous thrombosis plus pulmonary embolism. The unsettled relations between surgical performance and volume load is discussed also. Patient safety in the operating theatre is a most actual topic that recently deserved WHO attention and even became that organization’s priority.
ABSTRACT - Operation theatres are the health care spots where error and accident prevalence is higher. Those adverse events span from surgical flow interruptions to minor accidents to catastrophic events. The author reviews the activity areas where errors most likely occur and identifies their major determinants and mechanisms — human factors, system factors, team factors, task complexity, ambiance and pure chance. Typical errors and error patterns are revisited, as well as their occurring mechanisms — wrong patient, wrong surgery, wrong organ, wrong side surgeries, unwanted foreign bodies left, surgical infection and deep venous thrombosis plus pulmonary embolism. The unsettled relations between surgical performance and volume load is discussed also. Patient safety in the operating theatre is a most actual topic that recently deserved WHO attention and even became that organization’s priority.
Descrição
Palavras-chave
Segurança Doentes Bloco operatório Erros Eventos adversos Patient safety Operating theatres Errors Adverse events
Contexto Educativo
Citação
Fragata, José I. G. - Erros e acidentes no bloco operatório : revisão do estado da arte = Accidents and errors in the operating theatre : incidence and mechanisms. Revista Portuguesa de Saúde Pública. ISSN 0870-9025. Volume temático, Nº 10 (2010), p. 17-26
Editora
Universidade Nova de Lisboa, Escola Nacional de Saúde Pública