Priorities and root cause analysis of quality and safety problems in chilean hospitals / Prioridades y análisis de las causas de los problemas de calidad y seguridad en hospitales chilenos

BACKGROUND: Quality improvement is an important component of hospital operations. AIM: To prioritise clinical quality and safety problems in Chilean hospitals according to their severity, frequency, and detectability. MATERIAL AND METHODS: The study was conducted between December 2018 and June 2019. To identify quality and safety problems, an exploratory study was conducted using an online survey aimed to those responsible for clinical quality and safety in Chilean hospitals. The survey was sent to 94 hospitals and completed by quality management personnel at 34 hospitals, yielding a total of 25 valid surveys for analysis. Based on the information gathered, a risk priority score was computed to rank the problems surveyed. Focus groups were held to find the root causes of the quality and safety problem with the highest risk priority score. RESULTS: The three highest risk priorities were:1 ineffective interprofessional communication,2 lack of leadership for addressing frequently recurring safety issues, and3 antimicrobial resistance due to inappropriate use of antibiotics. For the communication problem, the focus group found two main root causes: those due to personnel and those relating to the hospitals themselves. CONCLUSIONS: Hospitals can systematically use the proposed approach to categorize their main clinical quality and safety problems, analyze their causes, and then design solutions.

ANTECEDENTES: La mejora continua de la calidad es un componente importante en las actividades hospitalarias. OBJETIVO: Priorizar los problemas de calidad y seguridad en hospitales chilenos de acuerdo a su severidad, frecuencia y detectabilidad. MATERIAL Y MÉTODOS: Se efectuó un estudio exploratorio con una encuesta en línea para detectar problemas de calidad y seguridad, dirigida a quienes están a cargo de los problemas de calidad y seguridad en los hospitales. La encuesta fue enviada a 94 hospitales y respondida por los encargados de calidad y seguridad en 34 de ellos, lográndose 25 encuestas válidas para análisis. El estudio se llevó a cabo entre diciembre de 2018 y junio de 2019. Se diseñó una escala de prioridades de riesgo para determinar la importancia relativa de los problemas detectados. Se llevaron a cabo grupos focales para determinar las causas del problema más importante. RESULTADOS: En Chile, los problemas de calidad y seguridad más importantes son la falta de comunicación interprofesional, falta de liderazgo para abordar los problemas de seguridad y calidad, y resistencia a antibióticos debido a su uso inapropiado. Problemas relacionados al personal y relacionados al hospital fueron las causas primarias de la falta de comunicación. CONCLUSIONES: Los hospitales podrían utilizar este enfoque de forma sistemática para categorizar sus principales problemas de calidad y seguridad, analizar las causas y diseñar soluciones.

In Vitro Cytotoxicity Analysis of Bioceramic Root Canal Sealers on Human Gingival Fibroblast Cells

ABSTRACT@#This study evaluated the cytotoxicity of four bioceramic root canal sealers (bioceramic sealers): GuttaFlow Bioseal (GB), MTA Fillapex, CeraSeal Bioceramic root canal sealer (CS), and iRoot SP root canal sealer (iRSP). The viability of human gingival fibroblast (HGF) cells was used to evaluate the cytotoxicity of these bioceramic sealers. HGF cells were cultured and exposed to bioceramic sealer extracts for 24 hours, 48 hours and 72 hours at 37°C in an incubator humidified with 5% CO2. The 3-(4, 5-dimethylthiazol-2-yl)-2, 5-diphenyltetrazolium bromide or MTT assay was conducted to determine cell viability at each incubation period and compared among all bioceramic sealers. The Kruskal-Wallis test revealed statistically significant differences between the positive control group and MTA Fillapex, MTA Fillapex and GB, and between GB and iRSP with p < 0.05. However, no statistical differences were found in cell viability for each material across all the incubation periods. GB was the least cytotoxic bioceramic sealer with cell viability exceeding 90% throughout the 72-hour incubation followed by CS, iRSP, and MTA Fillapex with non-cytotoxicity after 72-hour incubation, mild cytotoxicity after 72-hour incubation, and mild cytotoxicity after 72-hour incubation, respectively. However, iRSP showed moderate cytotoxicity, and MTA Fillapex was severely cytotoxic (< 30% cell viability) after 24-hour incubation.

Metodologías validadas para el análisis causal de eventos adversos de trascendencia clínica en la biomedicina / Methodologies validated for the causal analysis of adverse events of clinical relevance in biomedicine

Introducción: El análisis causal de los eventos adversos amerita metodologías validadas para establecer la dinámica de cómo se originan los incidentes que afectan la seguridad del paciente en los ambientes de prestación de servicios de salud. Objetivo: Describir las bases conceptuales y metodológicas de los sistemas de análisis causal de eventos adversos de trascendencia clínica en la biomedicina. Métodos: Se realizó una revisión documental empleando la bibliografía nacional e internacional actualizada. Se utilizó el motor de búsqueda Google Académico, se consultaron artículos de libre acceso en las bases de datos Pubmed y SciELO, desde marzo 2019 hasta igual mes de 2020. Se emplearon como palabras clave: eventos adversos, análisis de causas raíz, seguridad del paciente, según los Descriptores en ciencias de la salud (DeCS). Fueron seleccionados 25 artículos (20 en idioma español, 5 en inglés), de ellos, 18 (72,0 por ciento) corresponden a los últimos 5 años. Análisis e integración de la información: Las metodologías del análisis causa-raíz, el método ANCLA, el análisis modal de fallos y efectos (AMFE) y el protocolo de Londres, comparten como propósito su función de usar el evento o error para revelar las brechas que vulneran la seguridad del paciente y los aspectos inadecuados en el proceso de atención de la salud. Conclusiones: Los sistemas de análisis causal de eventos adversos constituyen herramientas para incrementar la cultura de seguridad del paciente, pues detectan fallas y errores latentes en el sistema, cuya corrección es esencial para implementar estrategias de prevención(AU)

Introduction: Causal analysis of adverse events requires validated methodologies to determine the origin of incidents affecting patient safety in health care settings. Objective: Describe the conceptual and methodological bases of the systems for the causal analysis of adverse events of clinical relevance in biomedicine. Methods: A document review was conducted of updated national and international bibliography. The search was carried out in the search engine Google Scholar, and open access papers were consulted in the databases PubMed and SciELO from March 2019 to March 2020. The key words used were adverse events, root cause analysis and patient safety, obtained from Health Sciences Descriptors (DeCS). A total 25 papers were selected (20 in Spanish and 5 in English), of which 18 (72.0 percent had been published in the last five years. Data analysis and integration: Root-cause analysis methodologies, the ANCLA score, the failure modes and effects analysis (FMEA) and the London Protocol share the common purpose of using events or errors to reveal gaps that weaken patient safety and inappropriate aspects of the health care process. Conclusions: Systems for the causal analysis of adverse events are tools to enhance patient safety culture, for they detect failures and errors latent in the system whose correction is essential to implement prevention strategies(AU).

Costs and root causes of medication errors and falls in a Teaching Hospital: cross-sectional study / Costos y causas principales de los errores y caídas de medicación y caídas en un Hospital Docente: un estudio transversal / Custos e causas-raízes de erros de medicação e quedas em Hospital de Ensino: estudo transversal

ABSTRACT Objectives to characterize accidents/falls and medication errors in the care process in a teaching hospital and to determine their root causes and variable direct costs. Method cross-sectional study implemented in two stages: the first, was based on the analysis of secondary sources (notifications, medical records and cost reports) and the second, on the application of root-cause analysis for incidents with moderate/severe harm. The study was carried out in a teaching hospital in Paraná, which exclusively serves the Brazilian Unified Health System and composes the Network of Sentinel Hospitals. Thirty reports of accidents/falls and 37 reports of medication errors were investigated. Descriptive statistical analysis and the methodology proposed by The Joint Commission International were applied. Results among the accidents/falls, 33.3% occurred in the emergency room; 40.0% were related to the bed, in similar proportions in the morning and night periods; 51.4% of medication errors occurred in the hospitalization unit, the majority in the night time (32.4%), with an emphasis on dose omissions (27.0%) and dispensing errors (21.6%). Most incidents did not cause additional harm or cost. The average cost was R$ 158.55 for the management of falls. Additional costs for medication errors ranged from R$ 31.16 to R$ 21,534.61. The contributing factors and root causes of the incidents were mainly related to the team, the professional and the execution of care. Conclusion accidents/falls and medication errors presented a low frequency of harm to the patient, but impacted costs to the hospital. Regarding root causes, aspects of the health work process related to direct patient care were highlighted.

RESUMEN Objetivos caracterizar accidentes/caídas y errores de medicación en el proceso asistencial en un hospital universitario y; determinar sus causas fundamentales y los costos directos variables. Método estudio transversal implementado en dos etapas: la primera, basada en el análisis de fuentes secundarias (notificaciones, historias clínicas e informes de costos) y; el segundo, en la aplicación del análisis raíz-raíz para incidentes con daños moderados / severos. Realizado en un hospital docente de Paraná, que atiende exclusivamente al Sistema Único de Salud y forma parte de la Red de Hospitales Centinelas. Se investigaron 30 notificaciones de accidentes / caídas y 37 de errores de medicación. Se aplicó el análisis estadístico descriptivo y la metodología propuesta por The Joint Commission International. Resultados entre los accidentes / caídas, el 33,3% ocurrió en urgencias; 40,0% estaban relacionados con la cama, en proporciones similares en los periodos de mañana y noche; El 51,4% de los errores de medicación ocurrieron en la unidad de internación, la mayoría durante la noche (32,4%), con énfasis en omisiones de dosis (27,0%) y errores de dispensación (21,6%). La mayoría de los incidentes no resultaron en daños o costos adicionales. El costo promedio fue de R$ 158,55 para el manejo de caídas. Los costos adicionales por errores de medicación oscilaron entre R$ 31,16 y R$ 21.534,61. Los factores contribuyentes y las causas fundamentales de los incidentes se relacionaron principalmente con el equipo, el profesional y la ejecución de la atención. Conclusión los accidentes / caídas y los errores de medicación tuvieron una baja frecuencia de daño al paciente, pero impactaron los costos hospitalarios. En relación a las causas raíz, se destacaron aspectos del proceso de trabajo en salud, relacionados con la atención directa al paciente.

RESUMO Objetivos caracterizar os acidentes/quedas e erros de medicação no processo de cuidado em um hospital de ensino e; determinar suas causas-raízes e os custos diretos variáveis. Método estudo transversal implementado em duas etapas: a primeira se pautou na análise de fontes secundárias (notificações, prontuários e relatórios de custos) e; a segunda, na aplicação de análise de cauza-raíz para incidentes com danos moderados/graves de julho a dezembro de 2019. Realizado em hospital de ensino do Paraná, que atende exclusivamente o Sistema Único de Saúde e compõe a Rede de Hospitais Sentinelas. Foram investigadas 30 notificações de acidentes/quedas e 37 de erros de medicação. Aplicaram-se a análise estatística descritiva e a metodologia proposta pela The Joint Comission International. Resultados dentre os acidentes/quedas, 33,3% ocorreram no pronto socorro; 40,0% tiveram relação com o leito, em proporções semelhantes nos períodos matutino e noturno; 51,4% dos erros de medicação ocorreram em unidade de internação, a maioria no período noturno (32,4%), com destaque para omissões de dose (27,0%) e erros de dispensação (21,6%). A maioria dos incidentes não ocasionou danos ou custo adicional. O custo médio foi R$ 158,55 para manejo das quedas. Os custos adicionais para erros de medicação variaram entre R$ 31,16 e R$ 21.534,61. Os fatores contribuintes e causas-raízes dos incidentes se relacionaram, principalmente, à equipe, ao profissional e à execução do cuidado. Conclusão os acidentes/quedas e erros de medicação apresentaram baixa frequência de danos ao paciente, porém impactaram no custo hospitalar. Em relação às causas-raízes, destacaram- se os aspectos do processo de trabalho em saúde, relacionados ao cuidado direto ao paciente.

Covid-19, causas fundamentais,classe social e território / COVID-19, fundamental causes, social class and territory / Covid-19, causas fundamentales, clase social y territorio

Resumo A teoria que considera as condições sociais como causas fundamentais da saúde, em articulação com as noções de classe social e território, é usada em reflexões acerca da trajetória e da distribuição dos efeitos da pandemia da Covid-19 no país. Parte-se de sínteses teóricas, abordagens e evidências de trabalhos do autor sobre desigualdade de saúde no Brasil. Entende-se que o 'meio social', de natureza relacional e estruturada, afeta a propagação e a distribuição da doença entre os grupos. As diferenças de classe em circunstâncias de trabalho, localização e moradia são referidas. No tocante às diferenças sociais no risco de desenlace fatal da doença, são consideradas a distribuição prévia de condições adversas e as diferenças no modo como as instituições de saúde processam as pessoas. Como proposto pela teoria, as desigualdades de recursos, informações, disposições e capacidade estariam afetando a distribuição social dos efeitos da pandemia no Brasil.

Abstract The theory of social conditions as fundamental causes of health, in conjunction with the notions of social class and territory, is used in reflections about the trajectory and distribution of the effects of the Covid-19 pandemic in the country. It starts with theoretical syntheses, approaches and evidences from the author's works on health inequality in Brazil. It is understood that the 'social environment', of a relational and structured nature, affects the spread and distribution of the disease among the groups. Class differences in circumstances of work, location and housing are mentioned. Regarding social differences in the risk of fatal outcome of the disease, the previous distribution of adverse conditions and differences in the way health institutions process people are considered. As proposed by the theory, inequalities in resources, information, dispositions and capacity would be affecting the social distribution of the effects of the pandemic in Brazil.

Resumen La teoría de las condiciones sociales como causas fundamentales de la salud, junto con las nociones de clase social y territorio, es utilizada en reflexiones sobre la trayectoria y distribución de los efectos de la pandemia de Covid-19 en el país. El punto de partida son síntesis teóricas, enfoques y evidencias de los trabajos del autor sobre la desigualdad en salud en Brasil. Se entiende que el "entorno social", de naturaleza relacional y estructurada, afecta la propagación y distribución de la enfermedad entre los grupos. Se mencionan las diferencias de clase en circunstancias de trabajo, ubicación y vivienda. Con respecto a las diferencias sociales en el riesgo de desenlace fatal de la enfermedad, se considera la distribución previa de condiciones adversas y las diferencias en la forma en que las instituciones de salud procesan a las personas. Según lo propuesto por la teoría, las desigualdades en recursos, información, disposiciones y capacidad estarían afectando la distribución social de los efectos de la pandemia en Brasil.

Impacto de um modelo de melhoria da qualidade na redução de erro relacionado à administração de vacina em Unidade Básica de Saúde / Impact of a quality improvement model on reducing errors related to vaccine administration in a Basic Health Unit

Justificativa: em minha atuação como enfermeira de uma Unidade Básica de Saúde (UBS), me deparei, com frequência, com as dúvidas dos profissionais de enfermagem sobre o manejo seguro das vacinas, incluindo dose correta segundo faixa etária, intervalo entre doses e faixa etária alvo da vacina. Tais dúvidas tinham potencial para resultar em danos aos usuários e, por este motivo, o presente estudo foi proposto. Objetivo: Avaliar o impacto de um programa de melhoria da qualidade na redução de erro relacionado à administração de vacina. Método: estudo observacional voltado para a comparação de medidas de resultados antes (Fase I) e após (Fase II) a implementação de um programa de melhoria da qualidade, segundo o referencial teórico e metodológico do Institute for Healthcare Improvement (IHI). O estudo foi realizado em uma UBS do interior do estado de São Paulo, no período de março a setembro de 2019. O universo em estudo foi constituído por 164 doses de vacinas preparadas e administradas por 15 técnicas de enfermagem. Para a coleta de dados foi utilizado um formulário eletrônico desenvolvido na Plataforma on-line Survey Monkey®. O estudo foi realizado em duas fases: na primeira, realizou-se a observação direta e participante dos profissionais de enfermagem durante o preparo e a administração das doses (linha de base). Em seguida, os resultados foram apresentados para a equipe de enfermagem da UBS e foi estabelecida uma equipe de melhoria da qualidade. Foram utilizadas as seguintes ferramentas da qualidade: análise de causa raiz; diagrama de Ishikawa; diagrama de Pareto e ciclos PDSA (Plan-Do-Study-Act). Foi estabelecida a meta de 100% de orientações realizadas aos usuários da UBS que necessitavam de vacinas e/ou aos responsáveis, sobre potenciais reações adversas em um período de seis meses. O planejamento das ações foi realizado com o auxílio do formulário PDSA do IHI. Na Fase II, quatro ciclos PDSA foram realizados para testar as mudanças que incluíram: capacitação da equipe de enfermagem da UBS sobre os principais eventos adversos relacionados às vacinas e orientações aos familiares/responsáveis sobre o risco do uso do celular na sala de vacina. Resultados: No primeiro Ciclo PDSA, 13 (72,2%) usuários/responsáveis foram orientados sobre potenciais reações adversas relacionadas às vacinas; contudo, cinco (27,7%) usuários/responsáveis não receberam tais orientações. No segundo Ciclo PDSA, das 30 doses administradas, houve orientações sobre possíveis reações adversas para 100% dos usuários/responsáveis. No terceiro e quarto Ciclos PDSA, essa porcentagem se manteve e foi confirmada a melhoria no processo. Conclusão: Os resultados demonstram que a abordagem de melhoria da qualidade, baseada em ciclos PDSA, contribuiram com a redução de erro no processo de administração de vacinas em uma UBS, na medida que houve aumento da porcentagem de orientações realizadas aos usuários e/ou responsáveis sobre potenciais reações adversas e que a mudança foi sustentável, pois se manteve ao longo do tempo. Implicações para a prática clínica: A equipe de enfermagem se mostrou mais segura quanto à realização dos procedimentos relacionados ao preparo e à administração de vacinas após a capacitação e demonstrou maior envolvimento nos processos, a partir da definição e construção deste projeto de melhoria. Ainda que não fosse o objetivo do estudo, o método selecionado também permitiu que os profissionais de enfermagem se atentassem para outras falhas nos processos que poderiam resultar em danos ao usuário; tais como: manutenção de agulhas nos frascos-ampolas após aspiração das doses e não realização da assepsia da pele antes das injeções. Durante as etapas do estudo, esses problemas foram sanados e as mudanças se mantiveram ao longo do tempo. A metodologia de melhoria da qualidade também contribuiu para o envolvimento da equipe médica na tomada de decisão sobre as mudanças a serem testadas. Têm-se como produto técnico deste projeto de melhoria a capacitação da equipe de enfermagem sobre o tema "Reações adversas às vacinas"; capacitação da equipe de enfermagem sobre abordagem ao usuário e/ou responsável sobre as principais reações adversas relacionadas à administração de vacinas; elaboração e disponibilização, para a equipe, de folder contendo os tipos de vacina e suas reações locais e sistêmicas; elaboração e disponibilização, na sala de vacina, de folder de proibição do uso de celular pelos usuários e/ou responsáveis.

Justification: in my work as a nurse at a Basic Health Unit (UBS), I have often come across questions from nursing professionals about the safe management of vaccines, including the correct dosage according to age group, dose interval, and the target age range of the vaccine. Such doubts had the potential to result in harm to users, and for this reason, the present study was proposed. Objective: To evaluate the impact of a quality improvement program in reducing errors related to vaccine administration. Method: observational study aimed at comparing measures of results before (Phase I) and after (Phase II) the implementation of a quality improvement program, according to the theoretical and methodological framework of the Institute for Healthcare Improvement (IHI). The study was carried out at a UBS in the São Paulo's interior, from March to September 2019. The universe under study consisted of 164 doses of vaccines prepared and administered by 15 nursing techniques. An electronic form developed at online platform Survey Monkey® was used for data collection. The study was conducted in two phases: In the first, direct observation and participation of nursing professionals during preparation and doses administration was performed (baseline). The results were then presented to the UBS nursing team and a quality improvement team was established. The following quality tools were used: root cause analysis; Ishikawa diagram; Pareto diagram and rapid PDSA (Plan-Do-Study-Act) cycles. A goal of 100% guidance to UBS users who needed vaccines and/or those responsible for potential adverse reactions over a six-month period was established. The actions planning was carried out with PDSA's help form from IHI. In Phase II, four PDSA cycles were conducted to test the changes that included: training of the UBS nursing team on major vaccine related adverse events and guidance to family/guardians about the risk of using cell phones in the vaccine room. Results: In the first PDSA Cycle, 13 (72.2%) users/responsibles were advised on potential adverse reactions related to vaccines; however, five (27.7%) users/responsibles did not receive such guidance. In the second PDSA Cycle, of the 30 doses administered, there was guidance on possible adverse reactions for 100% of the users/responsibles. In the third and fourth PDSA Cycles, this percentage was maintained and improvement in the process was confirmed. Conclusion: The results shows that the quality improvement approach, based on PDSA cycles, has contributed to reducing errors in the vaccine administration process at a UBS, as there has been an increase in the percentage of guidance provided to users and/or guardians about potential adverse reactions and the change has been sustainable because it has been maintained over time. Implications for clinical practice: The nursing team proved to be safer about performing procedures related to vaccine preparation and administration after training and also showed greater involvement in the processes, from the definition and construction of this improvement project. Although it was not the objective of the study, the method selected also allowed nursing professionals to pay attention to other failures in the processes that could result in damage to the user, such as: maintenance of needles in vials after doses aspiration and not performing skin asepsis before injections. During the study's stages, these problems were remedied and the changes were maintained over time. The quality improvement methodology also contributed to the involvement of medical team making the decision about the changes that will be tested. The technical product of this improvement project is about training the nursing team on "Adverse reactions to vaccines"; approaching the nursing team on how to user and/or responsible person on the main adverse reactions related to vaccine administration; preparation and availability for the team of a folder containing the types of vaccine and their local and systemic reactions; preparation and availability folder in the vaccine room prohibiting the use of cell phones by users and/or responsible persons.

Sobrevida e perda marginal óssea de implantes de diâmetro estreito de liga titânio-zircônia e titânio puro / Survival rate of titanium-zirconium narrow diameter dental implants and commercially pure titanium narrow diameter dental implants

Apesar da existência de diversos estudos que validem o uso de implantes de diâmetro estreito, a maioria é baseada em ligas de titânio puro. Há pouca evidência clínica em relação ao sucesso do implantes de diâmetro estreito de titânio-zircônia (TiZr NDIs), no que diz respeito à taxa de sobrevida (SR) e perda óssea marginal (MLB). O objetivo desta revisão sistemática foi analisar sistematicamente SR, assim como MBL de TiZr NDIs quando comparados a implantes de diâmetro estreito de titânio comercialmente puro (cpTi NDIs). A busca foi conduzida nas bases Medline/Pubmed, Cochrane, Scopus e Embase (do ano 2000 a novembro de 2016). Foram incluídos estudos clínicos do tipo coorte e randomizados. Dos 3453 artigos inicialmente identificados, foram incluídos seis estudos clínicos. Não houve diferença estatisticamente significante em taxa de sobrevida quando comparados os grupos TiZr NDIs e cpTi NDIs, em um ano de acompanhamento (p=0,5), além disso, também não houve diferença na comparação entre região de implantação (anterior ou posterior) no grupo TiZr NDIs. Não houve diferença entre os grupos anterior e posterior em relação à taxa de sobrevida em um ano: -0,01 (95% CI, -0,05 a 0,03) e perda óssea marginal: -0,01 mm (95% CI: -0,14 a 0,12). Pode-se concluir que TiZr NDIs apresentam taxas de sucesso e reabsorção óssea peri-implantar similares às de cpTi NDis.

Análisis causa-raíz sobre evento adverso producido en la Clínica Odontológica Docente Asistencial, Facultad de Odontología, Universidad de La Frontera, Chile / Cause-root analysis on an adverse event generated at the Dental Clinic, Faculty of Dentistry, Universidad de La Frontera, Chile

El Análisis de Causa-Raíz (ACR) es una forma de estudio retrospectivo de eventos adversos destinado a detectar las causas subyacentes de los mismos para proteger a los pacientes mediante la modificación de los factores dentro del sistema de salud que los provocaron y prevenir sus recurrencias. Si bien esta concepción centrada en la seguridad del paciente ha visto un importante auge en la atención médica, la odontología no ha sido llevada de igual manera probablemente por presentar daños más leves, procedimientos ambulatorios (con la consiguiente falta de seguimiento de muchos eventos adversos) y prácticas fundamentalmente privadas (cuyos conflictos afectarían potencialmente los resultados comerciales). Dado que no hay precedentes en Chile, se presenta un evento adverso producido en la Clínica Odontológica Docente Asistencial de la Facultad de Odontología de la Universidad de La Frontera y su ACR, desarrollado como primera intervención del Centro Chileno para la Observación y Gestión del Riesgo Sanitario de esa institución. Se plantean las necesidades de implementar un sistema explícito de categorización de eventos adversos en esa disciplina y de apoyar políticas de cultura en seguridad para el paciente odontológico, y se discute el papel de las instituciones universitarias para reconocer las áreas de vulnerabilidad en sus clínicas y así reforzar y mejorar la calidad de sus prácticas sanitarias.

Root cause analysis (RCA) is a retrospective study of adverse events performed to detect the underlying causes of these events to protect patients by modifying the factors within the health system that caused them and preventing their recurrences. Although this paradigm focused on patient safety has seen a significant increase in medical care, dentistry has not been carried out in the same way, probably because of milder injuries, outpatient procedures (with the consequent lack of follow-up of many adverse events) and basically private practices (whose conflicts would potentially affect commercial outcomes). Since there is no precedent in Chile, we present an adverse event produced at the Dental Clinic of the Faculty of Dentistry of the University of La Frontera and its RCA, performed as the first intervention of the Chilean Center for the Observation and Management of Health Risk of that institution. The needs to implement an explicit system of categorization of adverse events in this discipline and to provide support for cultural safety policies for the dental patient are discussed. The role of university institutions in recognizing areas of vulnerability in their clinics and to strengthen and improve the quality of their health practices is also discussed.

La fundamentación médico legal / The legal medical foundation

Resumen:La Fundamentación, es el apartado del dictamen médico legal, donde el médico forense plasma, de forma clara, precisa y detallada, los motivos que sustentan su criterio para emitir las conclusiones. Ésta, es la base de la pericia médico legal, dado que se exponen todos los elementos de juicio disponibles al momento de realizar un peritaje y le permite a la Autoridad Judicial darle o restarle validez a la pericia médico legal, como elemento de prueba.

Abstract:The foundation is the legal opinion of the medical section, where the coroner plasma, a clear, accurate and detailed the reasons that support your judgment to make findings. This is the basis of forensic expertise, since all available evidence when making an expertise and allows the Judicial Authority or subtract give validity to the forensic expertise as evidence are presented.

Mortalidad infantil en la provincia de Río Negro: estudio cualitativo con análisis causa-raíz / Infant mortality in the province of Río Negro: qualitative study with root cause analysis

INTRODUCCIÓN: la tasa de mortalidad infantil (TMI) de Río Negro es menor a la media nacional. En la 4a Zona Sanitaria se registró un aumento en los últimos tres años, con especial impactoen la mortalidad neonatal con causas reducibles. OBJETIVOS: Mediante análisis causa raíz (ACR), estudiar casos seleccionados y proponer estrategias para disminuir las muertes infantiles en la zona. Analizar la mortalidad infantil (MI) en la Zona Sanitaria entre 2011 y 2013. MÉTODOS: Se realizó un análisis de casos seleccionados con un estudio descriptivo transversal. Se utilizó el ACR para el estudio cualitativo de 14 casos entre octubre de 2012 y febrero de 2014. Se clasificaron los factores asociados a las muertes según las siguientes áreas: recursos humanos, institucional, factores externos y ambiente hospitalario, equipamiento e insumos. Se resumió en un diagramade Pareto, y se usó un gráfico causa raíz por caso. Se analizó la MI y sus componentes de acuerdo con variables epidemiológicas en 2011, 2012 y 2013. RESULTADOS: El 80% de los aspectos relacionados con la mortalidad correspondieron a recursos humanos y factores institucionales. Los fallecidos tuvieron edad gestacional, peso al nacery Apgar a los 5 minutos más bajos que la población de recién nacidos del período. No hubo diferencias significativas en la edad y educaciónmaterna. CONCLUSIONES: Una gran proporción de la MI regional es reducible. Las estrategias surgidas del análisis apuntan a mejorar la capacitación y cambiar la cultura organizacional. El ACR permite identificar los errores en los procesos de atención y generar propuestas.

INTRODUCTION: the child mortality rate in Río Negro province is lower than national average. In the 4th Health Area, there was an increase in the last three years, with high impact on neonatal mortality and reducible causes. OBJECTIVES: Through root cause analysis (RCA), to study selected cases and to propose strategies to decrease child mortality in the region. To analyze child mortality in the 4th Health Area from 2011 to 2013. METHODS: An analysis of selected cases was performed, with a descriptivecross-sectional study. The RCA was used for a qualitative study of 14 cases from October 2012 to February 2014. Death-related factors were classified in groups: human resources, institutional factors, external factors, hospital environment, and equipment and supplies. Results were displayed in a Pareto diagram, using a root cause graph in each case. The study analyzed child mortality and its components according to epidemiological variables in 2011, 2012 and 2013. RESULTS: Among death-related aspects, 80% were part of human resources and institutional factors. Gestational age, birth weight and Apgar at 5 minutes were lower in dead children than in general newborn population. There wasno significant difference regarding maternal age and education. CONCLUSIONS: A large proportion of child mortality is reducible. The analysis-based strategies aim at improving training and changing organizational culture. RCA allows to detect health care process problems and to generate proposals.

High-risk medication use and patient safety

Medication safety is a significant issue in hospitals everywhere. Although the number of errors caused by high risk medication is less common, the impact on the patient is more critical due to their potentially fatal outcome. Great improvements are needed to reduce errors and increase this aspect of patient safety. Several health quality organizations have reported a list of high-risk medications and useful clinical guidelines, including improving communication, standardizing medication order protocols, providing decision-support tools, and continually monitoring for errors. It is evident that systemic redesign would be more effective in quality improvement; however, given that the medication process is not the same in each institute, root cause analysis based on each error report should be carried out to improve medication safety. Moreover, it is worth noting that leadership should play an important role in the creation of a culture that supports and promotes a strong health and safety performance of an organization.

High-risk medication use and patient safety

Medication safety is a significant issue in hospitals everywhere. Although the number of errors caused by high risk medication is less common, the impact on the patient is more critical due to their potentially fatal outcome. Great improvements are needed to reduce errors and increase this aspect of patient safety. Several health quality organizations have reported a list of high-risk medications and useful clinical guidelines, including improving communication, standardizing medication order protocols, providing decision-support tools, and continually monitoring for errors. It is evident that systemic redesign would be more effective in quality improvement; however, given that the medication process is not the same in each institute, root cause analysis based on each error report should be carried out to improve medication safety. Moreover, it is worth noting that leadership should play an important role in the creation of a culture that supports and promotes a strong health and safety performance of an organization.

An analysis of surgical outcome and influencing factors in patients of congenital basilar invagination with atlantal-axial dislocation: report of 120 cases / 中华外科杂志

<p><b>OBJECTIVE</b>To investigate the surgical outcome and its influencing factors in patients of congenital basilar invagination (BI) with atlanto-axial dislocation (AAD).</p><p><b>METHODS</b>From May 2004 to August 2010, 120 patients who had BI with AAD were surgically treated with direct posterior intraoperative distraction-reduction and fixation technique, 93 patients were successfully followed up by means of questionnaire survey, telephone and clinical evaluation. Pre- and postoperative dynamic cervical X-rays, computed tomographic scans, 3-dimentional reconstruction views and magnetic resonance imaging were performed. Pre- and postoperative Japanese Orthopaedic Association (JOA) score, distance between odontoid tip and Chamberlain's line and atlantodental interval were measured to evaluate the surgical result. Statistical analysis was performed by means of paired t test and Pearson Correlation analysis.</p><p><b>RESULTS</b>There were 93 cases were followed up for 24-99 months with an average of 46.5 months. Until the final follow-up, clinical symptoms were improved in 79 patients (84.9%), and were stable in 7 patients (7.5%) and deteriorated in 4 patients (4.3%). Three patients died postoperatively (3.2%). Patients without intramedullary signal intensity change (ISIC) had better surgical outcome. Patients with compression from anterior odontoid tip and posterior bone margin of occipital foramen had the worst surgical outcome (F = 3.987, P < 0.01). Overall, good decompression and bone fusion were shown on postoperative image in 87 patients (93.5%). There were 3 deaths in this series because of basilar artery thrombosis, posterior fossa hematoma and unknown reasons each.</p><p><b>CONCLUSIONS</b>The direct posterior intraoperative distraction-reduction and fixation technique is an effective simple and safe method for the treatment of BI with AAD. Anterior compression from odontoid tip and posterior compression from bone margin of occipital foramen-atlantal posterior arch play important roles in its developing mechanism. ISIC on MRI is a predictive factor for the worse surgical outcome.</p>

Mortalidad neonatal: análisis causa raíz: estudio prospectivo de los factores vinculados a la muerte de recién nacidos internados en maternidades seleccionadas del sector público de la República Argentina / Neonatal mortality: root cause analysis: prospective study of factors related to the death of newborns admitted to selected maternity of the public sector of Argentina

Objetivo: identificar y caracterizar a los RN que fallecen en 5 principales maternidades públicas y explorar factores relacionados a las muertes reducibles a través del análisis de Causa Raíz (ACR). Métodos: Estudio prospectivo multicéntrico, descriptivo y observacional. Estrategia cuantitativa de corte transversal y cualitativa tipo ACR. Resultados: durante 10 meses se produjeron 238 muertes neonatales sobre 22.324 nacimientos más 651 RN derivados (TM global 10,35‰). La media de PN de los fallecidos fue 1838 ± 999 g y la mediana 1635 g (1000-2650) y la de edad gestacional 32 ± 5 sem. La edad materna fue de 25 ± 7años y sólo el 20% no tuvo ningún control en su embarazo. Las principales causas de internación fueron dificultad respiratoria (42%), malformaciones (39%), infecciones y asfixia perinatal. El 65% presentó alguna complicación en la evolución. La principal causa de muerte fueron las malformaciones congénitas (38%) seguida por la infección intrahospitalaria (27%). Con respecto al ACR la dimensión institucional (coordinación de la atención, experiencia, capacitación, infección hospitalaria) estuvo vinculada a 48% de las muertes mientras que la dimensión RRHH fue la más frecuentemente reconocida como deficitaria y relacionada con el evento muerte (57%). El 56,7% de las muertes fueron clasificadas como potencialmente reducibles, oscilando entre 35,5% y 76,2% según los centros. Conclusiones: La mayor parte de las muertes neonatales analizadas parecen reducibles. Dentro de las medidas preventivas necesarias a nivel de los sistemas y procesos, resulta fundamental establecer estrategias de capacitación y fortalecimiento del recurso humano que asiste a esta población vulnerable.