Implementation Of Safety Strategies Research Articles

Tranexamic acid at cesarean delivery: Drug-error deaths.

The use of tranexamic acid for postpartum hemorrhage has entered obstetrical practice globally with the evidence-based expectation of saving lives. This improvement in the care of women with postpartum hemorrhage has come at a price. For the anesthetist, having tranexamic acid ampoules close at hand would seem an obvious strategy to facilitate its use during cesarean delivery, an important setting for severe hemorrhage. Tragically, we have identified a number of recent instances of inadvertent intrathecal administration of tranexamic acid instead of local anesthetic for spinal anesthesia. Reported cases of this catastrophic error seem to be increasing. The profound neurotoxicity of tranexamic acid causes rapid-onset convulsions, with mortality of 50%. How can these tragic errors be averted? Drug safety alerts have been issued by the US Food and Drug Administration and the World Health Organization, but that is not enough. We recommend extensive dissemination of information to raise awareness of this potential hazard, and local hospital protocols to ensure that tranexamic acid is stored separately from anesthetic drugs, preferably outside the operating room and with an auxiliary warning label. Implementation of safety strategies on a very large scale will be needed to ensure that the life-saving potential of tranexamic acid is not eclipsed by drug-error mortality.

Tranexamic acid at cesarean delivery: drug-error deaths.

The use of tranexamic acid for postpartum hemorrhage has entered obstetrical practice globally with the evidence-based expectation of saving lives. This improvement in the care of women with postpartum hemorrhage has come at a price. For the anesthetist, having tranexamic acid ampoules close at hand would seem an obvious strategy to facilitate its use during cesarean delivery, an important setting for severe hemorrhage. Tragically, we have identified a number of recent instances of inadvertent intrathecal administration of tranexamic acid instead of local anesthetic for spinal anesthesia. Reported cases of this catastrophic error seem to be increasing. The profound neurotoxicity of tranexamic acid causes rapid-onset convulsions, with mortality of 50%. How can these tragic errors be averted? Drug safety alerts have been issued by the US Food and Drug Administration and the World Health Organization, but that is not enough. We recommend extensive dissemination of information to raise awareness of this potential hazard, and local hospital protocols to ensure that tranexamic acid is stored separately from anesthetic drugs, preferably outside the operating room and with an auxiliary warning label. Implementation of safety strategies on a very large scale will be needed to ensure that the life-saving potential of tranexamic acid is not eclipsed by drug-error mortality.

Tranexamic acid at cesarean delivery: drug-error deaths

The use of tranexamic acid for postpartum hemorrhage has entered obstetrical practice globally with the evidence-based expectation of saving lives. This improvement in the care of women with postpartum hemorrhage has come at a price. For the anesthetist, having tranexamic acid ampoules close at hand would seem an obvious strategy to facilitate its use during cesarean delivery, an important setting for severe hemorrhage. Tragically, we have identified a number of recent instances of inadvertent intrathecal administration of tranexamic acid instead of local anesthetic for spinal anesthesia. Reported cases of this catastrophic error seem to be increasing. The profound neurotoxicity of tranexamic acid causes rapid-onset convulsions, with mortality of 50%. How can these tragic errors be averted? Drug safety alerts have been issued by the US Food and Drug Administration and the World Health Organization, but that is not enough. We recommend extensive dissemination of information to raise awareness of this potential hazard, and local hospital protocols to ensure that tranexamic acid is stored separately from anesthetic drugs, preferably outside the operating room and with an auxiliary warning label. Implementation of safety strategies on a very large scale will be needed to ensure that the life-saving potential of tranexamic acid is not eclipsed by drug-error mortality.

Tranexamic acid at cesarean delivery: drug-error deaths

The use of tranexamic acid for postpartum hemorrhage has entered obstetrical practice globally with the evidence-based expectation of saving lives. This improvement in the care of women with postpartum hemorrhage has come at a price. For the anesthetist, having tranexamic acid ampoules close at hand would seem an obvious strategy to facilitate its use during cesarean delivery, an important setting for severe hemorrhage. Tragically, we have identified a number of recent instances of inadvertent intrathecal administration of tranexamic acid instead of local anesthetic for spinal anesthesia. Reported cases of this catastrophic error seem to be increasing. The profound neurotoxicity of tranexamic acid causes rapid-onset convulsions, with mortality of 50%.How can these tragic errors be averted? Drug safety alerts have been issued by the US Food and Drug Administration and the World Health Organization, but that is not enough. We recommend extensive dissemination of information to raise awareness of this potential hazard, and local hospital protocols to ensure that tranexamic acid is stored separately from anesthetic drugs, preferably outside the operating room and with an auxiliary warning label. Implementation of safety strategies on a very large scale will be needed to ensure that the life-saving potential of tranexamic acid is not eclipsed by drug-error mortality.

Contribuições da extensão universitária como estratégia de assistência na promoção da segurança do paciente

Objetivo: relatar a experiência extensionista do Programa de Extensão Gestão do Cuidar em Saúde, da Universidade Estadual de Santa Cruz. Método: relato de experiência das ações desenvolvidas entre abril/2017 e setembro/2018, pelos componentes do Projeto de Extensão, e a Comissão de Controle de Infecção Hospitalar, na construção de um material educativo produzido com a finalidade de contribuir com a formação de uma Cultura de Segurança do Paciente na implantação do Núcleo de Segurança do Paciente em um hospital do Sul da Bahia. Resultados: inicialmente elaboraram-se oito cartilhas sobre as metas de segurança do paciente e, posteriormente, rodas de conversas com profissionais de saúde da rede hospitalar para disseminação do conhecimento e formação de grupos de trabalhos para a construção dos protocolos de segurança do paciente. Participaram da ação aproximadamente 100 profissionais de saúde. Conclusão: essa ação possibilitou a docentes e discentes atuarem de forma multidisciplinar, na implantação das estratégias de segurança do paciente, contribuindo para a redução de riscos decorrentes da assistência à saúde.

Physicians Should Play a Role in Ensuring Safe Firearm Ownership.

The USA is unique among industrialized nations in its dramatic rate of firearm violence. Unfortunately, firearm-related issues in America are politically divisive and fraught with controversy, thus impeding the study and implementation of safety strategies. Despite the lack of consensus, there is agreement that firearms should be kept away from individuals with criminal intent and those who are dangerous due to medical impairment. While predicting criminal intent remains challenging, assessment of medical impairment remains a viable target. One approach in which physicians could contribute their expertise includes training a subset of doctors to perform specialized medical evaluations as a prerequisite for gun ownership. Such a process is not unprecedented, as physicians currently have a role in protecting the public's safety through assessments for commercial drivers, pilots, and train operators. Certified physician examiners could conduct these evaluations with a focus on evaluating objective, skill-based metrics to limit potential evaluator bias. The results of the medical evaluation would then be considered by an existing regulatory body to determine if disqualifying criteria are present. This proposal provides a mechanism for trained physicians to meaningfully participate in addressing an alarming public health issue, while still working within existing legal frameworks.

Hospitalisation due to sports-related injuries among children and adolescents in New South Wales, Australia: An analysis on socioeconomic and geographic differences

This population-based epidemiological study aims to investigate the associations between socioeconomic status, geographic location, and sports-related injuries among children and adolescents in New South Wales (NSW), Australia. Data utilised in this study were collected as part of the routine vital health information system via all hospitals in NSW. Included were all patients aged between 5-19 years admitted to a hospital because of sports-related injuries in NSW between 1996 and 2000. The crude age-and-sex-specific hospitalisation rates (/100,000 population-years) by socioeconomic levels and geographic residential locations were calculated. Negative Binomial regression analyses were also performed to examine the associations between socioeconomic status, geographic location and the rate of hospitalisation after adjusting for the age and sex of children and adolescents. The results indicated a significant association between geographic location and hospitalisation due to sports-related injury, after adjusting for age, sex, and socioeconomic status. The risk of hospital admission with sports-related injury among children and adolescents in rural areas was nearly 10% higher than for those in the metropolitan areas (RR=1. 12, 95%C.I.=1.07-1.32)). However, no association between socioeconomic status and hospitalisation with sports-related injury was found. Greater efforts are required in the implementation of safety strategies in research, training, and education for the prevention of sports-related injury in rural areas.