THE NEUROLOGICAL EMERGENCIES
"The man rushes into the error faster than the rivers run into the sea." Voltaire.
A significant portion of patients presenting to the emergency department with neurological symptoms, and in this context, the most common symptoms are headache, back pain, drowsiness and seizures. Then we highlight that in relation to headaches, they constitute about 2% of visits to emergency rooms. They have shown the diagnostic failures subarachnoid hemorrhage from 12 to 25%, which are probably related to the variety of clinical presentations, not following an "algorithm work" not understand the limitation of scales and neurological diagnostic tests and also ; because not all patients with subarachnoid hemorrhage have a sharp picture with headache, and in some people the headache improves with painkillers. (158)
Among other reasons for neurological consultation that can lead to errors described:
Back pain. Among the most common etiologies are ponytail compression, disc herniation, tumors, abscesses and hematomas. For proper diagnosis along with a good history and a thorough physical examination, Nuclear Magnetic Resonance (NMR) is needed. The cauda equina syndrome may be misdiagnosed when there is an incomplete medical history, physical examination errors in communication between doctors or between doctors and nursing staff. (159)
Drowsiness, is another reason to consult the neurological emergency; when an individual comes showing widespread sleepiness, you may have some toxic-metabolic problems ranging from electrolyte abnormalities, dehydration, medication side effects or systemic infections. Less common causes include drowsiness generalized Guillain Barré syndrome, an autoimmune disorder of unknown etiology and that usually occurs in adults 30 to 50 years; transverse myelitis neurological condition due to an inflammatory process of the white matter of the spinal cord, which can cause axonal demyelination; myasthenia gravis is also mentioned, a disease characterized by a pathological muscle weakness or fatigue caused by an autoimmune disorder; periodic paralysis (rare hereditary condition that causes progressive muscle weakness episodes whose two most common types are hypercalcemic and hypocalcemic); and botulism poisoning or bacterial neurotoxin produced by Clostridium botulinum (the most common route of poisoning is food). (160)
Dizziness. As well as headache, dizziness is another condition that can have from a benign to a very serious connotation, and this can make it difficult to distinguish; one element that affects the error of interpretation is the use by patients inadequate to describe their own symptoms words. In the case of sickness, the patient usually use the word "vertigo" or "revolving feeling" that are not useful to identify the picture. There is a fine line between mistake, such as a vestibular neuritis and labyrinthitis a cerebellar stroke or brain stem. Similarly, poor or inadequate physical examination as a wrong medical history leading to a misguided diagnosis. (161)
SAFETY, FAULTS AND ANESTHESIA.
latent conditions
"That they call truth is merely the elimination of errors." Georges Clemenceau.
The safe handling of anesthetic drugs has improved due to the advent of more reliable and safer drugs, as well as the existence of good quality equipment; but the use of polypharmacy, complex working conditions involving multiple medical and paramedical training standards in this area can be exposed to a medication error somewhere along the anesthetic procedure. Most of these errors can lead to high mortality and morbidity by prolonging hospital stay, the high cost of treatment and litigation. (162)
The Japanese Society of Anesthesiology (SJA), investigated 27 454 anesthetic procedures in a period of eight years (1999-2007) and found a total of 233 medical errors where overdose, drug substitution and omission of anesthetic drugs were present.(163)
Errors in the administration of the anesthetic medication
The anesthetic medication errors are divided into two groups according to the system of active and latent conditions job fails. Is considered "active fault" unsafe acts committed by anesthesiologists who are in direct contact with the patient due to errors in prescribing, judgment, inference and interpretation; whereas "latent conditions" mean that individuals within the health care system, make decisions with consequences not well considered in the future, for example: don´t anticipate side effects or after-effects that patients suffer. Alternatively errors fall into errors of omission and errors of commission. (164)
In anesthesia most critical accidents occur during induction (42%), and the beginning of the procedure (17%), also errors occur during the administration of medication 53%, followed by prescription 17%, and preparation transcription 11%.
It is believed that human error is a factor responsible for 65 to 87% of deaths during anesthesia, the drugs often related to medical error in the practice of anesthesia are inducing agents such as sodium pentothal, ketamine, relaxing muscle, narcotics, sedatives generally anticholinergic, local anesthetics (due to misidentification; labeling error, wrong syringe exchange with other drugs or medication.) (165)
Anesthesiologists are one of the few groups of physicians are personally responsible for the administration of a drug, during anesthesia most mistakes are totally or partially attributed to human error and inherent part of human psychology activity and therefore the occurrence of this can only be reduced, but not eliminated.
PREVENT MEDICAL ERRORS IN SURGERY
For decades the medical personal of surgical teams, has resorted to manually count sponges, needles, scissors, retractors for the opening of anatomical sites and other gadgets used during the operations before the end of the surgical procedure, sometimes more than one hundred, used computers that are recorded, for this reason, the University of Michigan has devised sponges with bar codes , which is scanned twice, first when used during the intervention and the second when removed from the body. If there is discrepancy in the count, the surgeon knows that he has to look in the area of surgical gauze or missing instrument. According to experts, the gauzes are objects that most often are forgotten in the body after surgery. X-ray equipment used to find lost objects while the patient is still in the operating room, x-ray can identify metal and soft objects. In addition, these new sponges with bar code contain a label that is opaque to the radiation, allowing to be detected during an x-ray. The Cardiovascular Center at the University of Michigan and the C.S. Mott Children Hospital, part of the initiative to prevent forgetfulness of surgical items held within the human body, in such a way that there has been no incident of this kind last year; and the researchers hope to extend it to other hospitals. (166)
THE MEDICAL ERRORS IN Transfusional Medicine
In recent decades, the health services of developed countries have devoted many resources to improve the biosecurity of blood for transfusion, the "transfusion chain" that goes from the donor to recipient through transfusion Blood Bank is safe and regulated, so that infection transmitted through a blood as globular concentrate, whole blood, fresh frozen plasma, cryoprecipitate, platelet concentrate. (167)
HAEMOVIGILANCE SYSTEMS
Within systems hemovigilance the SHOT (Serious Hazards of Transfusion) stands out, it's a control system transfusions using the UK requesting communication or report side serious adverse transfusion, including cases of "transfusion an incorrect blood component "(TCSI) where transfusion of a blood component that does not meet the specific needs or should be given to another patient is performed. (168)
Since 2000, also there have been "borderline incidents" in which an error was detected prior to blood transfusion, thus, important indicators of situations, which could appear an adverse outcome were obtained.
There are weak links in the chain of transfusion as decisions are often the justification for a transfusion errors in the application and prescription. These errors are due to a faulty or poorly documented the results of laborato
ry tests interpretation. The decision to prescribe a transfusion must be based on the existence of clinical signs and symptoms supported by laboratory results. If the results of laboratory tests do not correspond with the clinical picture of the patient, we must be very careful, because if they are wrong, they can have their origin in inadequate or errors in analytical samples. (169)
Likewise, the reports given by telephone may be susceptible to error and may refer to a different patient. Adverse events may also have originated from the doctor failed to provide essential information to the laboratory with respect to patient transfusion history or special needs (previous detection of alloantibodies or indication to irradiate blood components). (170)
Errors in the taking of samples, can be produced by labeling test tubes with samples away from the bed of the patient and the patient's identity is not checked, samples for diagnostic investigations cause sometimes inappropriate transfusions can have serious consequences . To reduce the risk of errors in sampling, the staff in charge of drawing blood, must be properly trained and if possible, evaluated. (171)
Lab errors in Blood Bank generally occur due to manual techniques urgent blood group determinations are themselves, and unsafe, and are associated with errors of interpretation and documentation. Unless the Blood Bank Service count fully staffed 24 hours a day, applications for transfusion at night should be limited only to those patients clinically justified.
There are basically two types of situations that may arise during indication of a blood component, and they are:
a) Failed component management
It is one episode in which a patient is transfused blood component that does not meet the appropriate requirements or was intended for another patient.
b) Incident void or "near misses"
Any mistake, that failure had been detected in time an incident in the transfusion process, but which when detected before transfusion, is avoided.
Serious medical errors in transfusion medicine
Severity 0: No clinical manifestations
Severity 1: Immediate signs without vital risk and full resolution of the condition.
Severity 2: Immediate signs with vital risk
Severity 3: Long-term morbidity
Severity 4: Death of patient
No data: No record data on gravity or have not been able to gather.
POST-TRANSFUSION immunological reactions
Reaction
Immune
Non immunologic
Immediate
• Immediate Hemolysis
• Anaphylaxis
• Hives
• Febrile reaction
Acute lung injury
Bacterial Contamination
• Hemolysis not immune
• Overload citrate
• Volume overload
• Overload potassium
Delayed
Delayed hemolysis
Post-transfusion purpura
Graft versus host reaction
Immunomodulation
Transmission
of infections
Hemosiderosis
Taken from: (101)