Prevención del error y seguridad del paciente en pediatría | 27 JUL 15

Incidentes de seguridad en la atención primaria

La naturaleza y la gravedad de los incidentes de seguridad pediátrica que ocurren en el ámbito de la medicina familiar y sus potenciales factores contributivos.
Autor/a: Philippa Rees, Adrian Edwards, Sukhmeet Panesar, Colin Powell, Ben Carter, Huw Williams, Peter Hibbert, Grad Dip Econ, Donna Luff, Gareth Parry, Sharon Mayor, Anthony Avery, Aziz Sheikh, Sir Liam Dona Safety Incidents in the Primary Care Office Setting
INDICE:  1.  | 2. 

1. Department of Health. An organization with a memory. London: Stationary Office; 2000
2. WHO. 10 Facts on Patient Safety.
Available at: www.who.int/features/factfiles/patient_safety/en/. Accessed June, 11, 2014
3. Committee on Quality of Health Care in America, Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academies Press; 2001
4. Sheikh A, Panesar SS, Larizgoitia I, Bates DW, Donaldson LJ. Safer primary care for all: a global imperative. Lancet Glob Health. 2013; 1(4):e182–e183
5. Carson-Stevens A, Edwards A, Panesar S, et al. Reducing the burden of iatrogenic harm in children. Lancet. 2015, In press.
6. Cresswell KM, Panesar SS, Salvilla SA, et al; WHO Safer Primary Care Expert Working Group. Global research priorities to better understand the burden of iatrogenic harm in primary care: an international Delphi exercise. PLoS Med. 2013; 10(11):e1001554
7. Hippisley-Cox J, Fenty J, Heaps M. Trends in consultation rates in general practice 1995 to 2006: analysis of the QRESEARCH database. QRESEARCH research highlights. Leeds: The Information Centre; 2007:29
8. Walsh KE, Bundy DG, Landrigan CP. Preventing health care-associated harm in children. JAMA. 2014; 311(17): 1731–1732
9. Pearson G. Why Children Die: A Pilot Study 2006 England (South West, North East and West Midlands), Wales and Northern Ireland. Confidential Enquiry into Maternal and Child Health. London: CEMACH; 2008
10. Department of Education. Child Death Reviews: Year Ending March 31, 2013. Available at: www.gov.uk/government/statistics/child-death-reviews-year-ending-31-march-2013. Accessed March 2015
11. Wolfe I, Macfarlane A, Donkin A, Marmot M, Viner R. Why Children Die: Death in Infants, Children and Young People in the UK. London: Royal College of Paediatrics and Child Health; 2014
12. Noble DJ, Panesar SS, Pronovost PJ. A public health approach to patient safety reporting systems is urgently needed. J Patient Saf. 2011; 7(2):109–112
13. Suresh G, Horbar JD, Plsek P, et al. Voluntary anonymous reporting of medical errors for neonatal intensive care. Pediatrics. 2004; 113(6).
Available at: www.pediatrics.org/cgi/content/full/113/6/e1609
14. Rees P, Evans H, Panesar S, Llewelyn M, Edwards A, Carson-Stevens A. Contraindicated BCG vaccination in “at risk” infants. BMJ. 2014; 349(7974):g5388
15. Rees P, Carson-Stevens A, Williams H, Panesar S, Edwards A. Quality improvement informed by a reporting and learning system. Arch Dis Child. 2014:99:702–703
16. National Reporting and Learning System. Organisation Patient Safety Incident Reports. Available: www.nrls.npsa.nhs.uk/patient-safety-data/organisationpatient-safety-incident-reports/.
Accessed September 10, 2014
17. WHO. The Conceptual Framework for the International Classification for Patient Safety. Available at: http://www.who.int/ patientsafety/taxonomy/icps_full_report.pdf. Accessed March 2015
18. Ritchie J, Spencer L. Qualitative data analysis for applied policy research. In: Bryman A, Burgess RG, eds. Analyzing Qualitative Data. London: Routledge; 1994:173–194
19. LINNEAUS Euro-PC. Patient Safety Incident Classification for Primary Care (PSIC-PC).
Available at: www.linneaus-pc.eu/cmsassets/documents/117326-607818.psicpc-version-31.pdf. Accessed March 2015
20. Green J, Thorogood N. Qualitative Methods for Health Research, 2nd ed. Thousand Oaks, CA: Sage; 2009
21. Hibbert PD, Runciman WB, Deakin A. A Recursive Model of Incident Analysis. Adelaide, Australia: Australian Patient Safety Foundation.
Available:www.apsf.net.au/dbfiles/A%20Recursive%20Model%20of%20Incident%20Analysis.pdf. Accessed March 2015
22. Latif A, Rawat N, Pustavoitau A, Pronovost PJ, Pham JC. National study on the distribution, causes, and consequences of voluntarily reported medication errors between the ICU and non-ICU settings. Crit Care Med. 2013; 41(2): 389–398
23. Harris DM, Westfall JM, Fernald DH, et al. Mixed methods analysis of medical error event reports: a report from the ASIPS Collaborative. In: Henriksen K, Battles JB, Marks ES, et al. ed. Advances in Patient Safety: From Research to Implementation, Vol. 2. Rockville, MD: Agency for Healthcare Research and Quality; 2005:133–147
24. Scobie A, Cook S. Analysis of health care error reports. In: Hurwitz B, Sheikh A, eds. Health Care Errors and Patient Safety. New York: Wiley & Sons; 2011
25. Reed JE, McNicholas C, Woodcock T, Issen L, Bell D. Designing quality improvement initiatives: the action effect method, a structured approach to identifying and articulating programme theory. BMJ Qual Saf. 2014; 23(12):1040–1048
26. NHS Institution for Innovation and Improvement. Quality and Service Improvement Tools: Driver Diagrams. Available:
www.institute.nhs.uk/quality_and_service_improvement_tools/quality_and_service_improvement_tools/driver_diagrams.html. Accessed February 14, 2015
27. Mays N, Pope C. Rigour and qualitative research. BMJ. 1995; 311 (6997):109–112
28. Sari AB, Sheldon TA, Cracknell A, Turnbull A. Sensitivity of routine system for reporting patient safety incidents in an NHS hospital: retrospective patient case note review. BMJ. 2007; 334(7584):79
29. Panesar SS, Cleary K, Sheikh A.Reflections on the National Patient Safety Agency’s database of medical errors. J R Soc Med. 2009; 102(7):256–258
30. Vincent C, Aylin P, Franklin BD, et al. Is health care getting safer? BMJ. 2008; 337(7680):a2426
31. Panesar SS, Carson-Stevens A, Salvilla SA, Patel B, Mirza SB, Mann B. Patient safety in orthopedic surgery: prioritizing key areas of iatrogenic harm through an analysis of 48,095 incidents reported to a national database of errors. Drug Healthc Patient Saf. 2013; 5:57–65
32. Pham JC, Gianci S, Battles J, et al. Establishing a global learning community for incident-reporting systems. Qual Saf Health Care. 2010; 19(5):446–451
33. Lawton R, Parker D. Barriers to incident reporting in a healthcare system. Qual Saf Health Care. 2002; 11(1):15–18
34. Lamont T, Watts F, Panesar S, MacFie J, Matthew D. Early detection of complications after laparoscopic surgery: summary of a safety report from the National Patient Safety Agency. BMJ. 2011; 342 (7790):c7221
35. Lamont T, Beaumont C, Fayaz A, et al.Checking placement of nasogástrico feeding tubes in adults (interpretation of x ray images): summary of a safety report from the National Patient Safety Agency. BMJ. 2011; 342 (7806):d2586
36. Harnden A, Mayon-White R, Mant D, Kelly D, Pearson G. Child deaths: confidential enquiry into the role and quality of UK primary care. Br J Gen Pract. 2009; 59(568):819–824
37. Thompson MJ, Ninis N, Perera R, et al.Clinical recognition of meningococcal disease in children and adolescents. Lancet. 2006; 367 (9508):397–403
38. WHO Regional Office for Europe. European Detailed Mortality Database. Available at: www.euro.who.int/en/whatwe-do/data-and-evidence/databases/european-detailed-mortalitydatabasedmdb2. Accessed January 17, 2015
39. Wolfe I, Cass H, Thompson MJ, et al. Improving child health services in the UK: insights from Europe and their implications for the NHS reforms. BMJ. 2011; 342(7803):d1277
40. Asthma UK. The asthma divide: inequalities in emergency care for people with asthma in England. London: 2007.
41. Milne C, Forrest L, Charles T. Learning from analysis of general practitioner referrals to a general paediatric department. Arch Dis Child. 2010; 95(Suppl 1):A71
42. Graber M, Gordon R, Franklin N. Reducing diagnostic errors in medicine: what’s the goal? Acad Med. 2002; 77(10):981–992
43. Wong IC, Wong LY, Cranswick NE. Minimising medication errors in children. Arch Dis Child. 2009; 94(2):161–164
44. Department of Health. Building a Safer NHS for Patients. Implementing an Organisation with a Memory. London: Stationary Office; 2001
45. Kohn LT, Corrigan JM, Donaldson MS. To Err Is Human: Building a Safer Health System. Washington, DC: National Academies Press; 1999
46. Cousins DH, Gerrett D, Warner B. A review of medication incidents reported to the National Reporting and Learning System in England and Wales over 6 years (2005-2010). Br J Clin Pharmacol. 2012; 74(4):597–604
47. Kaushal R, Bates DW, Landrigan C, et al. Medication errors and adverse drug events in pediatric inpatients. JAMA. 2001; 285(16):2114–2120
48. Blum KV, Abel SR, Urbanski CJ, Pierce JM. Medication error prevention by pharmacists. Am J Hosp Pharm. 1988; 45(9):1902–1903
49. Davis T. Paediatric prescribing errors. Arch Dis Child. 2011; 96(5):489–491
50. Conroy S, Sweis D, Planner C, et al. Interventions to reduce dosing errors in children: a systematic review of the literature. Drug Saf. 2007; 30(12): 1111–1125
51. Walsh KE, Kaushal R, Chessare JB. How to avoid paediatric medication errors: a user’s guide to the literature. Arch Dis Child. 2005; 90(7):698–702
52. Selbst SM, Fein JA, Osterhoudt K, Ho W. Medication errors in a pediatric emergency department. Pediatr Emerg Care. 1999; 15(1):1–4
53. Wilson DG, McArtney RG, Newcombe RG, et al. Medication errors in paediatric practice: insights from a continuous quality improvement approach. Eur J Pediatr. 1998; 157(9):769–774
54. Kaushal R, Goldmann DA, Keohane CA, et al. Medication errors in paediatric outpatients. Qual Saf Health Care. 2010; 19(6):e30
55. Rinke ML, Bundy DG, Velasquez CA, et al. Interventions to reduce pediatric medication errors: a systematic review [published online ahead of print July 14, 2014]. Pediatrics. doi:10.1542/peds.2013-3531
56. Poon EG, Keohane CA, Yoon CS, et al. Effect of bar-code technology on the safety of medication administration. N Engl J Med. 2010; 362(18):1698–1707
57. Levine SR, Cohen MR, Blanchard N, et al. Guidelines for preventing medicationerrors in pediatrics. J Pediatr Pharmacol Ther. 2001; 6: 426–442

 

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