Hybrid electronic record: An error reduction strategy for diverse medical prescription formats

Background: This project is part of a broader effort to develop a new electronic registry for ophthalmology in the KwaZulu-Natal (KZN) province in South Africa. The registry should include a clinical decision support system that reduces the potential for human error and should be applicable for our diversity of hospitals, whether electronic health record (EHR) or paper-based. Methods: Post-operative prescriptions of consecutive cataract surgery discharges were included for 2019 and 2020. Comparisons were facilitated by the four chosen state hospitals in KZN each having a different system for prescribing medications: Electronic, tick sheet, ink stamp and handwritten health records. Error types were compared to hospital systems to identify easily-correctable errors. Potential error remedies were sought by a four-step process. Results: There were 1307 individual errors in 1661 prescriptions, categorised into 20 error types. Increasing levels of technology did not decrease error rates but did decrease the variety of error types. High technology scripts had the most errors but when easily correctable errors were removed, EHRs had the lowest error rates and handwritten the highest. Conclusion: Increasing technology, by itself, does not seem to reduce prescription error. Technology does, however, seem to decrease the variability of potential error types, which make many of the errors simpler to correct. Contribution: Regular audits are an effective tool to greatly reduce prescription errors, and the higher the technology level, the more effective these audit interventions become. This advantage can be transferred to paper-based notes by utilising a hybrid electronic registry to print the formal medical record.

El rol del factor humano en el éxito de la práctica clínica odontológica / The role of the human factor in the success of dental clinical practice

Resumen Los fracasos y complicaciones en el campo de la cirugía bucal son analizados generalmente desde un punto de vista técnico o biológico. En términos generales, a partir del espíritu fragmentario del conocimiento, se tiende a enfocar la atención odontológica en la parte técnica y teórica. Actualmente se están produciendo cambios socioculturales que están generando modificaciones en los paradigmas de la atención odontológica, considerando también la comunicación con el paciente y la situación psicológica tanto del paciente como del equipo profesional. En este editorial se busca reflexionar sobre estos temas analizando perspectivas más integradas para lograr un mayor equilibrio en la atención profesional.

Abstract Failures and complications in the field of oral surgery are generally analyzed from a technical or biological point of view. In general terms, based on the fragmentary spirit of knowledge, dental care tends to be focused on the technical and theoretical knowledge. We are currently witnessing sociocultural changes that are producing modifications in the paradigms of dental care, also considering communication with the patient and the psychological situation of both the patient and the professional team. This editorial seeks to reflect on these issues, considering the most integrated visions to achieve greater balance in professional care.

El rol del factor humano en el éxito de la práctica clínica odontológica / The role of the human factor in the success of dental clinical practice

Los fracasos y complicaciones en el campo de la cirugía bucal son analizados generalmente desde un punto de vista técnico o biológico. En términos generales, a partir del es- píritu fragmentario del conocimiento, se tiende a enfocar la atención odontológica en la parte técnica y teórica. Actual- mente se están produciendo cambios socioculturales que están generando modificaciones en los paradigmas de la atención odontológica, considerando también la comunicación con el paciente y la situación psicológica tanto del paciente como del equipo profesional. En este editorial se busca reflexionar so- bre estos temas analizando perspectivas más integradas para lograr un mayor equilibrio en la atención profesional (AU)

Failures and complications in the field of oral surgery are generally analyzed from a technical or biological point of view. In general terms, based on the fragmentary spirit of knowledge, dental care tends to be focused on the technical and theoretical knowledge. We are currently witnessing so- ciocultural changes that are producing modifications in the paradigms of dental care, also considering communication with the patient and the psychological situation of both the patient and the professional team. This editorial seeks to re- flect on these issues, considering the most integrated visions to achieve greater balance in professional care (AU)

Human error causing inappropriate management of pregnancy associated breast cancer, literature review and experience in Niger delta university teaching hospital, Okolobiri, Bayelsa state, Nigeria

Breast cancer is the commonest cancer in women in Nigeria. Pregnancy Associated Breast Cancer (PABC) is breast cancer occurring in pregnancy up to one year after delivery. Due to some misconceptions, mistakes occur in the management of these patients leading to poor outcomes. There may be difficulties in the diagnosis of PABC due to the clinical features being mistaken for the normal physiologic changes of pregnancy. The physiologic changes may interfere with radiological and pathological interpretations. Fine needle aspiration cytology (FNAC) or a trucut biopsy confirms the diagnosis. There have been debates on maternal versus foetal wellbeing in PABC. Chemotherapy is safe after 10 weeks of pregnancy when organogenesis is complete. Delaying chemotherapy till after pregnancy worsens the prognosis. Hormonal treatment is contraindicated in PABC. Method: This is a retrospective observational study of cases of PABC at the Niger Delta University Teaching Hospital, Okolobiri, Bayelsa State, Nigeria, from January 2019 to January 2021. Results: Seven cases were seen with ages ranging from 28 to 37. All patients presented with breast lumps. Diagnosis was by FNAC and trucut biopsy. None of the patients received care for the cancer during pregnancy as they were advised by their doctors not to and to present after delivery due to the percermived haful effects of treatment on the foetus. All seven patients presented with advanced stage disease after delivery. They all received chemotherapy and hormonal therapy. Eventually all patients were lost to follow up. Conclusion: Patients diagnosed with PABC in peripheral hospitals should be referred for specialist care. Treatment modalities like surgery and chemotherapy are feasible in PABC and should not be unduly delayed. Continuing education on the topic and feedback to colleagues at peripheral hospitals should be ensured

Analysis of human error as a factor in road crash in Metro Manila (2005-2015)

Introduction@#In the Philippines, data on road traffic injuries show that road injury is the 11th leading cause of premature deaths in the Philippines. The World Health Organization estimates that 1.24 million die globally due to road traffic crashes. @*Objectives@#This study aimed to show the trend of the road crash situation in Metro Manila, Philippines, over eleven years (2005–2015) and to analyze human error and other associated hazard factors for road crashes. @*Methods@#This study is a secondary analysis of an 11-year database culled from 2005–2015, for Metro Manila, Philippines. The variables included road crash classification, incidence over months and time of the day, road crash disaggregated by location, region, and city, and type of vehicle. Descriptive statistics were used to describe the incidence of a road crash, road crash fatalities, and risk factors associated with a road crash in Metro Manila. @*Results@#The incidence of road crashes in Metro Manila has increased from 65,111 in 2005 to 95,615 in 2015. Fatalities also increased from 348 to 536. The most predominant type of vehicle involved in road crashes were cars from 46% to 67%, followed by jeepneys, vans, and motorcycles. The most commonly reported human errors were speeding, inattentive and bad turning. The reported percentage of speeding from 2005–2010 ranged between 32% and 58%. In 2014, speeding (96%) was the most reported human error among the other reported errors; such as inattentiveness (range, 28 to 41%) and bad turning (0.6% and 33%). Fatigue and traffic violation made up 0.02% to 0.45% of the reported human factors of road crash-related hospitalization cases in Metro Manila for the period. Suspected alcohol use accounted for 0.04% to 4.57% of the human errors reported. For non-fatal and fatal crashes, the associated human errors were suspected alcohol use, inattentiveness, and speeding. The highest adjusted residual for both fatal and non-fatal (injurious) crashes was for inattentiveness. Human error was associated with years, suggesting that for some years, the number of crashes caused by human errors is significantly higher than expected. Alcohol-suspected crashes are significantly higher than expected for 2005 and 2011, with 2011 having the highest adjusted residual. Inattentiveness-caused crashes were significantly higher than expected for years 2005 to 2010, with 2007 having the highest adjusted residual. Bad turning was significantly higher from 2005 to 2007; while disobedience was significantly higher for 2005 to 2008. Speeding was significantly higher than expected from 2005 to 2010. @*Conclusion@#There is a need to address the public health concern posed by road crashes in Metro Manila, as well as to rectify the ergonomically related risk factors and human error components in a road crash.

Sesgos cognitivos en anestesia, una causa latente de error humano / Cognitive biases in anesthesia, a latent cause of human error

Resumen: Un concepto que ha causado atención en los últimos años es el de los sesgos cognitivos y su influencia en las decisiones y comportamientos diarios de los seres humanos. Los equipos de trabajo en sala de operaciones se forman de diferentes áreas de especialidad y con distintos niveles de experiencia, todos tienen una función y pueden tomar decisiones que afectan al paciente. Este proceso de toma de decisiones se puede basar en experiencia previa, razonamiento clínico y el contexto; la necesidad de realizar diagnósticos y tratamiento rápido en algunas situaciones hace al anestesiólogo particularmente vulnerable a sesgos cognitivos. Presentamos diferentes ejemplos de sesgos cognitivos que se pueden llegar a presentar en sala de operaciones, como puede ser el sesgo de atención, en el cual un estímulo relevante como la necesidad de asegurar la vía aérea puede hacer que el estado hemodinámico del paciente pase desapercibido. El objetivo de este trabajo es crear conciencia particularmente en los anestesiólogos sobre estos sesgos cognitivos, su presencia en el proceso de toma de decisiones en la sala de operaciones y compartimos un par de formas para ayudar a prevenirlos.

Abstract: A concept that has gained attention in the last years is the existance of cognitive biases and their influence in decision making and behaviour of human beings. Teams in the operating room are formed by different medical specialities with varied levels of experience, everyone has a role and every one can make decisions that have an impact in the patient. This decision making process might be based in previous experience, clinical reasoning, and context; the need to make a rapid diagnosis and treatment in some situations makes the anesthesiologist especially vulnerable to cognitive bias. We present different types of cognitive bias that might be present in the operating room for example the attention bias in which a relevant stimulus like the airway management could make the hemodynamic aspect go unnoticed. The goal of this paper is to aware anesthesiologists in particular about this cognitive biases, their presence in the decision making process in the operating room and to share a couple of ways to prevent them.

Cognitive Model of a Semi-Mechanized Picking Operation / Modelo cognitivo de una operación de recolección semi-mecanizada / Modelo cognitivo de uma operação de colheita semimecanizada

Abstract Introduction: The current paper develops a pioneering approach to the human factors of picking operations, which are addressed from a cognitive perspective. Materials and methods: The model thus contributed is established through a qualitative methodology which, based on several theories, is articulated and applied to the real situation of a dry foods company's semi mechanized picking operation. Results: The results combine the cognitive architecture of the operation and its relations with logistic factors, in order to decrease human error and, therefore, increase service level. Conclusion: The current model provides elements for quantitative modeling, which could include this type of factors in order to optimize the picking operation of a supply chain.

Resumen Introducción: Este documento desarrolla un enfoque pionero sobre los factores humanos de las operaciones semi mecanizadas de selección, las cuales se abordan desde una perspectiva cognitiva. Materiales y métodos: El modelo aportado establece a través de una metodología cualitativa y a partir de varias teorías, es articulado y aplicado a la situación real de una operación de selección (picking semi) mecanizada de una empresa de alimentos secos. Resultados: Los resultados combinan la arquitectura cognitiva de la operación y sus relaciones con factores logísticos, para disminuir el error humano y, por lo tanto, aumentar el nivel de servicio. Conclusión: El modelo actual proporciona elementos para el modelado cuantitativo, el cual incluye este tipo de factores para optimizar la operación de picking de una cadena de suministro.

Resumo Introdução: Este documento desenvolve um enfoque pioneiro sobre os fatores humanos das operações semimecanizadas de seleção, as quais se abordam desde uma perspectiva cognitiva. Materiais e métodos: O modelo aportado estabelece através de uma metodologia qualitativa e a partir de várias teorias, é articulado e aplicado à situação real de uma operação de seleção (picking) semimecanizada de uma empresa de alimentos secos. Resultados: Os resultados combinam a arquitetura cognitiva da operação e suas relações com fatores logísticos, para diminuir o erro humano e, portanto, aumentar o nível de serviço. Conclusão: O modelo atual fornece elementos para modelagem quantitativa, que inclui este tipo de fatores para otimizar a operação de picking de uma cadeia de suprimentos.

Human Error Probability Assessment During Maintenance Activities of Marine Systems

BACKGROUND: Maintenance operations on-board ships are highly demanding. Maintenance operations are intensive activities requiring high manemachine interactions in challenging and evolving conditions. The evolving conditions are weather conditions, workplace temperature, ship motion, noise and vibration, and workload and stress. For example, extreme weather condition affects seafarers' performance, increasing the chances of error, and, consequently, can cause injuries or fatalities to personnel. An effective human error probability model is required to better manage maintenance on-board ships. The developed model would assist in developing and maintaining effective risk management protocols. Thus, the objective of this study is to develop a human error probability model considering various internal and external factors affecting seafarers' performance. METHODS: The human error probability model is developed using probability theory applied to Bayesian network. The model is tested using the data received through the developed questionnaire survey of >200 experienced seafarers with >5 years of experience. The model developed in this study is used to find out the reliability of human performance on particular maintenance activities. RESULTS: The developed methodology is tested on the maintenance of marine engine's cooling water pump for engine department and anchor windlass for deck department. In the considered case studies, human error probabilities are estimated in various scenarios and the results are compared between the scenarios and the different seafarer categories. The results of the case studies for both departments are also compared. CONCLUSION: The developed model is effective in assessing human error probabilities. These probabilities would get dynamically updated as and when newinformation is available on changes in either internal (i.e., training, experience, and fatigue) or external (i.e., environmental and operational conditions such asweather conditions, workplace temperature, ship motion, noise and vibration, and workload and stress) factors.

Comparisons of Subthreshold Versus Full Posttraumatic Stress Disorder Distinguished by Subjective Functional Impairment Among Train Drivers: A Population-Based Nationwide Study in South Korea

OBJECTIVE: Subthreshold posttraumatic stress disorder (SPTSD), a condition that meets the full symptomatic criteria of posttraumatic stress disorder (PTSD) without subjective functional impairment, has yet to be fully investigated. In this study, we aimed to determine the prevalence and characteristics of SPTSD. METHODS: The web-based survey including psychiatric diagnosis and experience of human error was conducted in actively working train drivers in South Korea. RESULTS: Of the 4,634 subjects, 103 (2.23%) were categorized as full PTSD and 322 (6.96%) were categorized as having SPTSD. Individuals with full PTSD showed higher impulsivity and anxiety compared to those with SPTSD and those without PTSD, while those with SPTSD had more frequent clinically meaningful depression, posttraumatic stress, and alcohol and nicotine dependence and significant human error. CONCLUSION: Despite not qualifying as a subjective functional disability, SPTSD still had significant psychiatric symptoms. More clinical attentions need to be given to the diagnosis and treatment of SPTSD.

Design of modular two-direction scalpel handle with easy assembly and disassembly / 医疗卫生装备

Objective To design a modular two-direction scalpel handle with easy assembly and disassembly to solve the problems of common handle in function singleness,directivity,assembling and disassembling,pick-up and etc.Methods A scalpel handle module involving in a single-groove two-direction tailstock,multifunctional handle and etc was designed according to international standards,which consisted of more than 10 kinds of instruments for orthopedic surgery and etc such as two-direction scalpel handle with easy assembly and disassembly,bent wrench,probe introducer,needle-knife remover and measuring tools.Simulation experiment,clinical trial and control test were carried out to verify the efficacy of the handle module.Results It's proved that the handle module gained advantages in safety,convenience,prevention of sharp instrument injury,decrease of human errors and etc.Conclusion The handle module behaves well in modularity,integration,multifunction,two-direction adaptability,easy assembly and disassembly,safety,storage and carrying,high costperformance ratio and etc,meets the requirements of Joint Commission on Accreditation of Healthcare Organization,and is suitable for military and civilian uses.

Human Error Analysis in a Permit to Work System: A Case Study in a Chemical Plant

BACKGROUND: A permit to work (PTW) is a formal written system to control certain types of work which are identified as potentially hazardous. However, human error in PTW processes can lead to an accident. METHODS: This cross-sectional, descriptive study was conducted to estimate the probability of human errors in PTW processes in a chemical plant in Iran. In the first stage, through interviewing the personnel and studying the procedure in the plant, the PTW process was analyzed using the hierarchical task analysis technique. In doing so, PTW was considered as a goal and detailed tasks to achieve the goal were analyzed. In the next step, the standardized plant analysis risk-human (SPAR-H) reliability analysis method was applied for estimation of human error probability. RESULTS: The mean probability of human error in the PTW system was estimated to be 0.11. The highest probability of human error in the PTW process was related to flammable gas testing (50.7%). CONCLUSION: The SPAR-H method applied in this study could analyze and quantify the potential human errors and extract the required measures for reducing the error probabilities in PTW system. Some suggestions to reduce the likelihood of errors, especially in the field of modifying the performance shaping factors and dependencies among tasks are provided.

Analysis of Erroneously Dispensed Named Generic Drugs / 医薬品情報学

<b>Objective: </b>The purpose of this study is to investigate incidents of erroneously dispensed drugs on the assumption that the incidents stem from the similar names of the drugs.  The investigation was also conducted to prevent such dispensing incidents in the future, i.e. to search for factors that can prevent future incidents, and finally to propose a prevention plan which takes each of these factors into account.<br><b>Methods: </b>We extracted incident cases related to generic drugs reported by pharmacies in Japan and from those cases examined those that were categorized as cases of erroneously dispensed medicine.  We used this data to categorize the difference in relationship between the drugs which were supposed to be prescribed and those which were erroneously dispensed, and to analyze the association between the “Flowchart for Avoiding Confusion Errors between Similarly Named Drugs” and the name similarity index based on this flowchart.<br><b>Results: </b>The types of incident cases due to name similarities of generic drugs were categorized into specification mistakes and brand mistakes.  The edit of the name similarity index were especially important factors for dispensing incidents between generic drugs.<br><b>Conclusion: </b>This study focusing on generic drugs revealed the factors that result in dispensing incidents due to name similarity.  Further empirical studies investigating the usefulness of interventions that alter the name similarity index is required.

El ambiente quirúrgico seguro: paradigma emergente en la práctica profesional de la cirugía / The safe surgical environment: emergent paradigm in the surgical professional practice

Desde que las Guerras Mundiales que se escenificaron en el siglo XX, en los teatros operacionales del conflicto en Europa, Norte de Africa, medio oriente, Asia, I y II Guerras Mundiales, Corea, Viet Nam, Afganistán Guerra Arabe- Israelí obligó a los países involucrados a atender a los millones de víctimas resultantes, planificando, organizando y rediseñando a pasos acelerados las estructuras de asistencia médica, capaces de suministrar recursos de atención masivo del trauma y estrategias para tratar a sus soldados y a la población civil. La consecuencia positiva para el avance de la medicina y especialmente de la cirugía de estos tragicos sucesos, fue la aparición y el desarrollo de la "cirugía compleja" y la conquista del abordaje quirúrgico de regiones del cuerpo humano, hasta ese momento vedados a la actividad del tratamiento quirúrgico: cavidad craneal, cirugía torácica, trauma cardiovascular, cirugía intestinal de urgencia, anestesia y manejo respiratorio, antibióticos, derivados sanguíneos, resucitación cardio-respiratoria y evacuación y trasporte de heridos. Varias décadas después el desarrollo de esta cirugía compleja, produjo un aumento desmesurado de la morbi-mortalidad ocasionado principalmente por los efectos de la anestesia inadecuada, hemorragias masivas, infección-sepsis y factores de error humano. Surgen entonces nuevas líneas de investigación clínica para identificar y disminuir estos factores. Esos esfuerzos logran al final del siglo XX y comienzos del XXI, resultados tangibles y eficaces mejorando los resultados finales de la cirugía. Por estos logros surge un nuevo paradigma en el mundo de la cirugía, conocido como "el ambiente quirúrgico seguro"; que comprende estrategias operativas y organizacionales, tales como: reingeniería de quirófanos, innovaciones tecnológicas, digitalización de aparatos de registro y la protección integral de los equipos humanos interactuantes en los servicios quirúrgicos. En este ensayo se describen...

Since the occurrence of the World Wars in the 20th. Century, at the military operational theatres in Europe, North Africa, Meddle East, Korea, Viet nam, Afghanistan and Israel the countries involved in these conflicts were forced to render medical care to the million of casualities in thousands of battlefields, specially organizing massive trauma care to military personnel also to civilian populations. The positive result of this tragic scenarios was that medicine as a whole and surgery, was the development of the so called "complex surgical care", and the conquest of the surgical approach of different regions of the human body, until then impossible to reach with therapeutic efficacy: intracranial structures, thoracic surgery, cardio-vascular injuries, acute intestinal trauma anesthesia and respiratory ventilation, antibiotics, blood replacement, cardio pulmonary resuscitation; and triage and the planning of transport of wounded soldiers. Some decades later, the development of the complex surgery reachers alarming levels of morbidity and mortality, mainly due to inadequate delivered anasthesia, massive hemorrhage, uncontrolled bacterial infections-sepsis and lethal consequences of human errors. New lines of clinical investigations and research conducted in the late XX century and early XXI century gave the answers to obtain strategies to diminish and fight this adverse factors; improving better outcomes for surgical therapies. This achievement gave birth to a new paradigm into the surgical world which is identified nowadays as the "safe surgical environment", compromising new strategies to redesing surgical operating rooms, application of technological discoveries, digitalization of patient's surveillance and bio protection of the surgical personnel avoiding events as accidents, thermal injuries, and infections with transmissible diseases in this scenario. In this paper will be described fundamental definitions of novel paradigm, reviewing concepts...

Analysis of Two Electrocution Accidents in Greece that Occurred due to Unexpected Re-energization of Power Lines

Investigation and analysis of accidents are critical elements of safety management. The over-riding purpose of an organization in carrying out an accident investigation is to prevent similar accidents, as well as seek a general improvement in the management of health and safety. Hundreds of workers have suffered injuries while installing, maintaining, or servicing machinery and equipment due to sudden re-energization of power lines. This study presents and analyzes two electrical accidents (1 fatal injury and 1 serious injury) that occurred because the power supply was reconnected inadvertently or by mistake.

Basic Knowledge of the Medical Ethic and Security : Frustrations Affecting the Doctor and the Patient / The Japanese Journal of Rehabilitation Medicine

The number of the patients requiring rehabilitation has been rapidly increasing. Rehabilitation patients and their families face various troubles and problems in their illness, their functional state, their convalescence, and a wide range of domains including their at-home life and care burden. And rehabilitation staffs must deal with these problems appropriately and take pride in their efforts and strive to provide continuing reliable care. However, most hospitals and rehabilitation centers only have one or at most a few physiatrists. Thus, most physiatrists and co-medical rehabilitation staff have few advisers and are frustrated by the many kinds of problems faced in providing medical service and management. In this lecture, I discuss how to build safety measures, how to write medical records to prevent future troubles, the proper on-site manner, and the 15 traits of a disliked physiatrist. I hope that this lecture can blow away the frustration from the rehabilitation scene and be helpful not only for patients and their families, but also for physiatrists and co-medical rehabilitation staff.

Human reliability in high dose rate afterloading radiotherapy based on FMECA / 中华放射医学与防护杂志

Objective To put forward reasonable and feasible recommendations against the procedure with relative high risk during the high dose rate (HDR) afterloading radiotherapy,so as to enhance its clinical application safety,through studying the human reliability in the process of carrying out the HDR afterloading radiotherapy.Methods Basic data were collected by on-site investigation and process analysis as well as expert evaluation.Failure mode,effect and criticality analysis (FMECA) employed to study the human reliability in the execution of HDR afierloading radiotherapy.Results The FMECA model of human reliability for HDR afterloading radiotherapy was established,through which 25 procedures with relative high risk index were found,accounting for 14.1％ of total 177 procedures.Conclusions FMECA method in human reliability study for HDR afterloading radiotherapy is feasible.The countermeasures are put forward to reduce the human error,so as to provide important basis for enhancing clinical application safety of HDR afterloading radiotherapy.

Study on application of human cognition reliability model in human error in emergency response against the source blockage of high dose rate afterloading unit / 中华放射医学与防护杂志

Objective To put forward reasonable and feasible recommendations aiming at enhancing the application safety of afterloading unit, through studying the human reliability in the emergency response against the source blockage of afterloading unit.Methods Based on the human cognition reliability model, ten operation errors during the emergency response against the source blockage of afterloading unit were analyzed and permissible time widow of emergency response operation were determined.The human error probability was calculated with the execution time of emergency response operation obtained through simulation, observation and recording.Results The operation action, relevant permissible time window and execution time were obtained with the corresponding human error probabilities in the range 0.04 - 0.27.Conclusions The human error model in emergency response against the source blockage of afterloading unit based on HCRmodel is feasible, and provides important reference basis to reduce the occurrence of potential exposure and mitigate the consequence of potential exposure.

Error humano y paro cardico intraoperatorio: ¿Un problema actual?

Introducción. La Anestesiología se identifica por el cuidado de la seguridad del paciente, que se corresponde con un decrecimiento de la mortalidad anestésica en los últimos años; sin embargo, no está libre de accidentes por errores, pues dada la frecuencia, variedad y potencia de las drogas que emplea, existe el riesgo potencial de un desliz y las consecuencias pueden ser desastrosas. Objetivo: Identificar las principales causas de paro cardiaco intraoperatorio relacionadas con error humano. Método: Se consultó bibliografía nacional e internacional relacionada con el tema, mediante la red nacional de información médica y sus importantes enlaces. Desarrollo: Se hizo una breve clasificación del error humano en dependencia de sus consecuencias u orígenes psicológicos, de las principales causas de error en anestesia y aquellas que pueden conducir a paro cardiaco intraoperatorio. Se hizo especial énfasis en las causas de complicaciones por error durante la anestesia neuroaxial y las implicaciones que puede tener la incorrecta comunicación entre los miembros del equipo de trabajo. Conclusiones: A pesar del importante decrecimiento de la mortalidad por causas anestésicas en los últimos años, el riesgo de paro cardiaco intraoperatorio derivado de errores humanos es un hecho, por lo que reconocer las principales causas que lo provocan es de obligatorio conocimiento para los profesionales de la especialidad con el propósito de disminuir su incidencia al máximo. Estos factores que influyen en la aparición de estos accidentes es fuente de estudio y experiencia. En nuestro país no existen informes al respecto.

Introduction: Anesthesiology is identified by care of patient's safety corresponding with a decrease of anesthesia mortality in past years; however, it is not free of accidents due to errors, since by frequency, variety and drugs potency, there is the possible risk of error and its consequences may be disastrous. Objective: To identify the major causes of intraoperative cardiac arrest related to a human error. Method: Authors reviewed the national and international bibliography related to with subject, using the medical information network and its important links. Develop: A brief classification of human error was carried our depending on its consequences or psychological origins, main causes of error in anesthesia and those that may leading to a intraoperative cardiac arrest. There was a special emphasis on causes due to error complications among the staff. Conclusions: Despite the significant decrease of mortality due to anesthesia causes in past years, the intraoperative cardiac arrest risk derived from human errors is a fact, it is mandatory that professionals of this specialty to know the major causes provoking it to decrease its incidence to the utmost. These factors influencing in appearance of these accidents is a study and experience source. In our country there aren't reports in this respect.

Analysis of human errors during trial examinations for the National Examination for Physicians: Preventive measures and educational effectiveness / 医学教育

We analyzed inadvertent human errors during 3-day trial examinations for the National Examination for Physicians. Sixth-year medical students sat for 2 different examinations consisting of 500 multiple-choice questions and chose either 1 or 2 correct answers. After the first examination, the students verified their errors and were provided with educational guidance to prevent inadvertent errors.1) More than half of the students made inadvertent errors during the examination.2)The errors occurred when the students solved questions or marked the answer sheets.3) Most of errors were either the selection of the wrong number of answer options (i.e., a 2-choice selection was required, but only 1 choice was selected) or the selection of choices that differed from the intended choices when the answer sheets were marked.4) After the students were taught how to avoid errors, the mean number of errors per examination per student decreased significantly from 2.1 to 1.0.5) To our knowledge, this is the first report to show the educational effectiveness of a method to decrease the rate of inadvertent errors during examinations.

Cultural Factors and Human Error in International Air Transportation Environment

Flightdeck behaviour and flight safety are influenced by the national, organizational, and professional cultures of crewmembers. National complexity of the operating environment ensure that error will be an inevitable occurrence. The influences of three cultures that are relevant to the cockpit are described; the professional culture of the pilots, organizational cultures, and the national cultures surrounding individuals and their organizations. This study review the cultural difference of crewmember in Korea based on Hofstede and Helmreich study. The study concludes with a suggestion of CRM in Korea as strategy necessary for a safety culture considering the multi-cultures cockpit.