Incidentes en oftalmología: estudio nacional en Argentina / Incidents in ophthalmology: A National Survey in Argentina

Resumen Objetivo: Realizar un análisis descriptivo de los incidentes en oftalmología reportados por médicos oftalmólogos de Argentina. Métodos: Se realizó un estudio basado en una encuesta desarrollada mediante un sistema electrónico, en agosto de 2021, dirigido a médicos oftalmólogos de Argentina. Se solicitó la descripción de incidentes oftalmológicos, clasificándolos en cuatro grupos, acorde a lo descrito por Organización Mundial de la Salud, en A: "Incidentes, casi-accidentes (no alcanzaron a los pacientes)"; B: "Incidentes (que alcanzaron al paciente, pero sin daño)"; C: "Incidentes prevenibles con daño" y D: "Incidentes no prevenibles con daño". El instructivo de la encuesta explicó la terminología y ofreció ejemplos de cada tipo de incidentes, que fueron evaluados mediante un proceso estadístico descriptivo. Resultados: Participaron 264 médicos oftalmólo gos quienes informaron 434 incidentes. A- Incidentes sin alcance al paciente: 125 casos (28.8%). B- Incidentes que alcanzaron al paciente sin daño: 117 casos. (27%). C- Incidentes prevenibles, con daño: 96 casos (22.1%). D- Incidentes no prevenibles con daño: 96 casos (22.1%). Los incidentes vinculados al uso de gotas fueron los más frecuentes en los 4 grupos (68, 75, 13 y 29 incidentes respectivamente). Conclusión: El 77.9% de los incidentes comunicados en este estudio se podrían haber evitado con adecuadas medidas de seguridad, siendo los más frecuentes los asociados a la utilización de gotas oftálmicas.

Abstract Objective: To perform a descriptive analysis of incidents in ophthalmology reported by ophthal mologists of Argentina. Methods: A questionnaire-based study was performed by an electronic survey during August 2021, including ophthalmologists of Argentina, requesting the description of ophthalmological incidents, which were classified in four groups, in accordance with World Health Organization Definition, as follow: A- "Inci dents, almost-accidents (patient no affected)"; B: "Incidents (patient affected without damage)"; C: "Preventable incidents, with damage", and D: "Not Preventable incidents, with damage". An instructive was supported in the survey explaining these definitions with examples of each kind of incidents. Data was processed for descriptive statistics. Results: The survey was performed by 264 ophthalmologists, reporting 434 incidents: A- Incidents, almost-accidents (patient not affected): 125 cases (28.8%). B- Incidents (patient affected without damage): 117 cases (27%). C- Preventable incidents, with damage: 96 cases (22.1%). D- "Not Preventable incidents, with damage: 96 cases (22.1%). In four groups the most frequent incidents were those associated with the use of ophthalmic drops (68, 75, 13, and 29 incidents respectively). Conclusion: Most of the incidents (77.9%) reported in this study could be avoided if appropriate safety measures were taken. Ophthalmic drops related incidents were the most frequent.

Errores conceptuales de estadística más comunes en publicaciones científicas / Common conceptual statistical mistakes in scientific literature / Equívocos comuns de estatísticas em publicações científicas

Resumen Este trabajo proporciona información actualizada sobre los errores estadísticos que comúnmente se cometen en la literatura científica y como estos podrían ser evitados. El objetivo principal es una revisión de manera conceptual de los errores estadísticos frecuentemente observados, así como defectos y trampas en la ciencia médica y veterinaria para ayudar a los investigadores a producir resultados estadísticamente correctos en sus futuras investigaciones. Al mismo tiempo, esta revisión podría ayudar a que los lectores de revistas científicas identifiquen análisis estadísticos o presentación de datos cuestionables y puedan estimar lo qué los autores habrían concluido si hubieran utilizado métodos estadísticos apropiados.

Abstract This work seeks to provide up-to-date information on commonly made statistical mistakes and statistical reports in scientific papers, and how these can be avoided. The main goal is to comprehensively review frequently observed statistical errors, flaws and pitfalls in medical and veterinary science in order to help researchers to produce statistically correct output in their future reports. At the same time, it can help readers to identify questionable statistical analysis, and estimate what the authors would have concluded when appropriate statistical methods have been used.

Resumo Este trabalho procura fornecer uma atualização sobre os erros estatísticos comumente cometidos na literatura científica e como eles podem ser evitados. O principal objetivo é analisar de uma maneira conceitual defeitos observados frequentemente, erros estatísticos e armadilhas na ciência médica e veterinária para ajudar os pesquisadores a produzir resultados estatisticamente corretos em futuras investigações. Ao mesmo tempo, esta revisão pode ajudar os leitores de revistas científicas a identificar análise estatística ou apresentação de dados questionáveis e estimar o que os autores teria concluído teve eles usaram métodos estatísticos adequados.

Practice of the Pediatric Pharmaceutical Services Based on WeChat Platform / 中国药房

OBJECTIVE:To investigate the effects of WeChat platform online service on the safety of pediatric family medica-tion and the quality of pharmaceutical care. METHODS:The online consultation records of"Qs and As for pediatric medications"were collected and summarized from the WeChat platform(WeChat ID:etyywd)during Jun.1st,2014-Dec.31st,2015 in our hos-pital. Statistical analysis was performed on the consulting time periods,age of pediatric patients with consultation demands,and the systems and mistake types involved in medication consultations. RESULTS:A total of 29 850 dialogue records on WeChat were collected,and 13 315 of these were related to medications(44.61%). The peak time of medication consultation was at 9:00-10:00 in the morning,with an accumulative consultation number of 1 840 cases(13.82%);while the least consultation time pe-riod was at 4:00-5:00 early in the morning,with only 13 cases(0.10%).Pediatric patients in need of consultation were more with-in the age of 1-6 years old,and most of them were preschool children(31.20%)and toddlers(26.32%). The systems consulted mainly involved the respiratory system,immune system and digestive system;in which respiratory system had the most cases (60.28%). There were 1 508 Qs and As records for medication mistakes that were occured or may occure and were corrected in time(11.33%),in which the mistake types were mainly the unsuitable use of antipyretics(3.91%),antibiotics abuse(3.14%), careless use of combination medication and excessive medication(3.04%),excessively large or small doses(0.69%),improper use of nebulized inhalant after discharge(0.41%),and excessive use of vitamins(0.14%). CONCLUSIONS:The WeChat plat-form expands the service scope of clinical pharmacists.As an extension of hospital pharmaceutical care,it reduces the risk of fami-ly medication mistakes due to a patient's or members'wrong recognition to a certain degree,reinforces communication between doctors and patients,and improves the experience of medical services.

Practice of the Pediatric Pharmaceutical Services Based on WeChat Platform / 中国药房

OBJECTIVE:To investigate the effects of WeChat platform online service on the safety of pediatric family medica-tion and the quality of pharmaceutical care. METHODS:The online consultation records of"Qs and As for pediatric medications"were collected and summarized from the WeChat platform(WeChat ID:etyywd)during Jun.1st,2014-Dec.31st,2015 in our hos-pital. Statistical analysis was performed on the consulting time periods,age of pediatric patients with consultation demands,and the systems and mistake types involved in medication consultations. RESULTS:A total of 29 850 dialogue records on WeChat were collected,and 13 315 of these were related to medications(44.61%). The peak time of medication consultation was at 9:00-10:00 in the morning,with an accumulative consultation number of 1 840 cases(13.82%);while the least consultation time pe-riod was at 4:00-5:00 early in the morning,with only 13 cases(0.10%).Pediatric patients in need of consultation were more with-in the age of 1-6 years old,and most of them were preschool children(31.20%)and toddlers(26.32%). The systems consulted mainly involved the respiratory system,immune system and digestive system;in which respiratory system had the most cases (60.28%). There were 1 508 Qs and As records for medication mistakes that were occured or may occure and were corrected in time(11.33%),in which the mistake types were mainly the unsuitable use of antipyretics(3.91%),antibiotics abuse(3.14%), careless use of combination medication and excessive medication(3.04%),excessively large or small doses(0.69%),improper use of nebulized inhalant after discharge(0.41%),and excessive use of vitamins(0.14%). CONCLUSIONS:The WeChat plat-form expands the service scope of clinical pharmacists.As an extension of hospital pharmaceutical care,it reduces the risk of fami-ly medication mistakes due to a patient's or members'wrong recognition to a certain degree,reinforces communication between doctors and patients,and improves the experience of medical services.

PRIMAVERA 2017: Errare humanum est

Cuando escribimos algo, el registro puede quedar para siempre… Y si aquello que escribimos tiene la característica de reproducirse ad infinitum, puede que no sea tan bueno. Los errores durante el trabajo de edición son comunes, tanto en el trabajo gráfico como en el fílmico; aunque menos frecuentes en el trabajo con sonido. En nuestro campo, son comúnmente llamados "errores de imprenta" debido a que es gracias a la imprenta que se reproducen, aunque pueden deberse a otros motivos y no a fallas técnicas durante el proceso de impresión. Pueden ser de diseño, de tipeo, ortográficos, semánticos, gramaticales, referenciales, de ordenamiento… Todos estos corresponden a la fase de edición. Esta se subdivide en fase computacional y fase de prueba de imprenta: La primera se realiza frente a un ordenador, página por página, cuidando que no ocurran, y ayudado por el corrector automático (el que a veces puede transformarse en un gran farsante). Una vez que la fase computacional está finalizada, se realizan impresiones en papel que se reparten a varias personas para que las lean y marquen los errores. Cuando la fase de edición no existe, los errores ocurren en gran profusión. Un tipo particular (llamado error por "copypaste") denota la ausencia de una fase de edición adecuada. Otro error interesante es el error por uso inadecuado de un término. Esto puede ocurrir por ignorancia del que redacta, por corrección automática del ordenador, o por asociación inadvertida con otro concepto similar, en la vorágine de la redacción. Un error (cuya publicación suele ser en extremo divertida para los lectores) ocurre cuando un miembro del equipo editorial ha hecho alguna broma escrita asociada a un texto, y ésta no se ha borrado Un tema estético ampliamente trabajado en edición, parte de la tradición e historia de este trabajo, es el llamado "control de viudas y huérfanas". Esto corresponde al manejo tipográfico (estético y de espacio) que hay que realizar con las líneas y palabras que quedan solas al final de un párrafo (viudas) o al principio o final de una página. Una línea viuda es aquella que, siendo la última de un párrafo, aparece al principio de la página o columna siguiente, por lo que se muestra aislada de su contexto y, por norma general, seguida de una línea en blanco que la separa del siguiente párrafo. Por contraparte, las huérfanas son la primera línea de un párrafo que queda sola al final de una página, con todo el resto del párrafo, que la contextualiza, en la siguiente. Si bien un artículo puede leerse sin mayores contratiempos sin controlar las viudas y huérfanas, es parte del trabajo de edición evitarlas, y entre nosotros su presencia es considerada un error (...)

Evaluación de errores preanalíticos en el laboratorio de planta del HIGA O. Alende de Mar del Plata / Evaluation of preanalytical mistakes in the routine laboratory of HIGA O. Alende of Mar del Plata / Avaliação de erros pré-analíticos no laboratório de rotina do HIGA O. Alende de Mar del Plata

La etapa preanalítica corresponde a todos los pasos que deben seguirse en orden cronológico hasta iniciar el procedimiento analítico. Los objetivos de este trabajo fueron evaluar los errores preanalíticos de los ingresos diarios a la planta del laboratorio con al menos una solicitud que involucrara a las secciones de Química Clínica y/o Hematología-Hemostasia, en el HIGA O. Alende de Mar del Plata. Se definió como error preanalítico (EPA) a todo error cometido en la solicitud/ingreso o en la extracción/recogida de la muestra. Se calculó el porcentaje de ingresos con uno o más EPA, la frecuencia de cada tipo de error, y la distribución de errores por servicio y por día de la semana. Se analizaron, en total, 7850 ingresos, de los cuales el 82% presentó uno o más EPA. Se relevó un total de 9141 errores, siendo el 91% en la solicitud/ingreso de la muestra. Se concluye que existe un elevado número de errores preanalíticos, de los cuales el mayor porcentaje se encuentra en la solicitud/ingreso. Dado que en el origen de estos errores participa gran parte del personal hospitalario, es importante concientizarlo para lograr la mejora en la calidad de los resultados de laboratorio, fundamentales para la toma de decisiones médicas.

The preanalytical phase involves all steps to be followed in chronological order until the start of the analytical procedure. The objectives of this study were to evaluate pre-analytical mistakes of the daily routine proceeds to the laboratory with at least one application involving sections of Clinical Chemistry and/or Hematology Hemostasis in HIGA O. Alende of Mar del Plata. They were defined as pre-analytical errors (EPA) any error in the application/ admission or extraction/collection of the sample. Were calculated the percentage of applications with one or more EPA, the frequency of each type of error, and the error distribution per service and day of week. Seven thousand and eight hundred and fifty applications were analyzed, of which 82% had one or more EPA. A total of 9141 errors were surveyed, with 91% errors in the application / admission of the sample. It was concluded that there are a large number of pre-analytical errors, of which the highest percentage is in the application / admission. Much of the hospital staff participates in the origin of these mistake; therefore it is important to sensitize them to achieve improved quality of laboratory results, essential for making medical decisions.

A fase pré-analítica corresponde a todos os passos a serem seguidos em ordem cronológica até o início do procedimento analítico. O objetivo deste estudo foi avaliar os erros pré-analíticos das admissões diárias no laboratório com, no mínimo, uma solicitação que envolva as seções de Química Clínica e/ou Hematologia-Hemostasia no HIGA O. Alende de Mar del Plata. Foi definido como erro pré-analítico (EPA), qualquer erro na solicitação/ admissão ou na extração/coleta da amostra. Foi calculado o percentual de admissões com um ou mais EPA, a frequência de cada tipo de erro, e a distribuição de erros por serviço e por dia da semana. No total, 7850 admissões foram analisadas, das quais 82% apresentou um ou mais EPA. Levantaram-se em total 9.141 erros, sendo 91% erros na solicitação/admissão da amostra. Conclui-se que há um grande número de erros pré-analíticos, dos quais o maior percentual se encontra na solicitação/admissão. Visto que na origem desses erros participa grande parte de funcionários do hospital, é importante sensibilizá-los para alcançar a melhoria da qualidade dos resultados laboratoriais, fundamentais para a tomada de decisões médicas.

Common mistakes in writing English medical papers and strategies to avoid them / 中华医学教育探索杂志

The language of English medical papers should be accurate, precise, clear and objective. Unfamiliar with these features and influenced by mother tongue, Chinese authors are prone to use unnecessary words, subjective expressions and long and confusing sentences, etc. To avoid those mistakes, they are suggested to practice a lot, keep a good reading habit and equip themselves with necessary searching skills, etc.

Errores preanalíticos en el laboratorio clínico de un hospital de tercer nivel: prueba piloto / Preanalytical mistakes at the clinical laboratory at a public hospital: pilot proof

Objetivo: Determinar la frecuencia y tipos de errores preanalíticos encontrados durante un mes en dos secciones del laboratorio clínico en un hospital público de tercer nivel. Materiales y métodos: Estudio descriptivo transversal; universo: 20268 muestras recibidas para análisis en dos secciones del laboratorio clínico; población objeto: 818 errores preanalí-ticos. Se registraron durante noviembre de 2008 todas las muestras que fueron rechazadas en las secciones de bioquímica y hematología por llegar en condiciones inadecuadas para su procesamiento. Se realizó un análisis descriptivo de la frecuencia de errores preanalíticos que se registraron; posteriormente se determinó la frecuencia de estos errores por servicios, secciones del laboratorio y horas y días de recepción de las muestras; adicionalmente se realizó un análisis por los turnos laborales que se manejan en el HUV. Los resultados se analizaron en el paquete estadístico EPI info 3.2 y SPSS 15.0. Resultados: Se identificaron 818 errores preanalíticos (frecuencia relativa del 4%). La distribución de errores fue: muestra coagulada, 42%; muestra hemolizada, 25%; volumen de muestra inadecuado, 23%; muestra mal marcada, 4%; muestra sin marcar, 3%; muestra en recipiente inadecuado, 2%; otras causas, 1% (tubo se quebró en la centrífuga, no llegó la muestra). El mayor número de errores se derivaron de los servicios de urgencias, unidad de cuidados intensivos adultos y quirúrgicos; estas no conformidades se concentraron principalmente en los días del fin de semana y en el turno de la noche. Conclusiones: En los análisis de especímenes clínicos existen muchas fuentes preanalíticas de error que generan rechazo de las muestras y el manejo de calidad total para los análisis de laboratorio requiere que el proceso en su totalidad sea manejado para reducir o, idealmente,eliminar todos los defectos dentro del proceso. Es importante detectar las desviaciones de los procesos porque así se diseñen e implementan planes de mejoramiento que conlleven a brindar un servicio de alta calidad.

Objective: Determinate the frequency and types of preanalytical errors found during a month at two sections of the clinical laboratory at a public hospital of third level. Materials y methods: transverse descriptive study, universe: 20268 samples received for analyses at two sections of the clinical laboratory, object poblation: 818 preanalytical errors. Were registered during the month of november of the 2008 year all samples rejected at the chemistry and hematology sections because arrive in inadequate conditions for to be processed; moreover, was realized a descriptive analyses of the frequency of registered preanalytical errors, then determinate the frequency of these errors by services, laboratory sections and hours and week days of samples reception, besides was realized a analyses by work shifts managed in the hospital. The results were analysed in the estadistics programs EPI info 3.2 y SPSS 15.0. Results: We identified 818 errors pre analytical (relative frequency of the 4 %). The distribution of errors was: Coagulated sample 42 %, hemolysed sample 25 %, inadequate volume of sample 23 %, wrongly marked sample 4 %, unmarked sample 3 %, inadequate container used 2 %, another causes (the tube broke in centrifugal, the sample did not arrive). The bigger number of errors derived of the services of urgencies, care intensive adult unit and surgical; these no conformities focused principally on the three days of the weekend and in the night turn. Conclusions: In the analyses of clinical specimens exists many pre analytical sources of error that generates rejection of samples. The managment of total quality for the analyses of laboratory requires than the total process be managed so as to reduce or, ideally, eliminate all defects within the process. It is important to detect the deviations of processes because thus draw and implement plans of improvement itself that entail to offer a high-quality service.

The abstract: the letter of presentation for a scientific paper / El resumen: la carta de presentación de un trabajo científico

The abstract is a part of scientific articles placed at the beginning of such.  It guides us quickly and accurately about the information we will find in the complete manuscript.  It must be written by selecting the appropriate words and sentences to achieve consistent, clear, and concise contents.  We can group the abstract into two types according to their content: the descriptive abstract, which guides the reader regarding the contents of the article but requires reading the full text for further details; and the informative abstract, which condenses the study and provides accurate data about the contents of the paper. The abstract has become a fundamental part of the scientific article, especially with the explosive growth of information; an adequate and well-built abstract allows scientists and researchers to recognize the work done by its authors.  Attention should be dedicated to its construction because the success of our publication depends upon the very abstract.

El resumen es un segmento del artículo científico que se ubica al inicio del mismo, y nos orienta en forma rápida y precisa sobre la información que encontraremos en el manuscrito completo. Debe ser escrito seleccionando adecuadamente las palabras y oraciones, para lograr un contenido coherente, claro y conciso. Podemos agrupar a los resúmenes en dos de acuerdo con su contenido: los descriptivos, que orientan al lector sobre el contenido del artículo y hacen necesaria una lectura del manuscrito para conocer detalles; y los informativos, que condensan el estudio pero brindan datos precisos sobre su contenido. El resumen se ha convertido en una pieza fundamental en un artículo, sobre todo con la creciente explosión de la información; además un resumen adecuado y bien construido permite que los científicos e investigadores reconozcan la labor realizada por sus autores. Debemos prestar mucha atención a su elaboración porque de él depende el éxito de nuestra publicación.

Errores estadísticos frecuentes al comparar dos poblaciones independientes / Frequent statistical errors while comparing two independent populations

The purpose of the present study is to show the methodological and statistical steps that biomedical researcher's mistake in order to avoid a misleading interpretation of common statistic indicators that are necessary to establish facts, and consequently, avoid mistaken theoretical conclusions based on empirically wrong misconstruction of facts when comparing two independent populations. The possible causes of this type or estimation are emphasized, and the adequate steps to be taken to avoid such causes are proposed.

El objeto del presente trabajo es mostrar los pasos metodológicos y estadísticos que los investigadores biomédicos deben realizar para evitar una mala estimación de estadígrafos que son necesarios para establecer hechos y, con ello, evitar inferencias teóricas erradas a partir de hechos empíricamente mal construidos cuando se comparan dos poblaciones. Se enfatiza en las causas posibles de este tipo de estimación y se proponen los pasos adecuados para evitar dichas causas.

Algunas reflexiones acerca de los errores más frecuentes encontrados en textos médicos traducidos del idioma inglés / Some reflections on the most frequent mistakes found in medical texts translated from English

Se analizan, a manera de reflexión, con ejemplos específicos algunos de los errores más frecuentes encontrados en textos médicos traducidos del idioma inglés desde diferentes ángulos, que incluyen: la terminación ing, la voz pasiva, las falsas cognadas, las expresiones idiomáticas, los decimales, los artículos, las mayúsculas, la polisemia, los extranjerismos, las preposiciones y errores de uso general.

Some of the most frequent mistakes found in medical texts translated from English are analyzed, and reflected on, from different angles: the ing ending, the passive voice, the false cognates, idioms, decimal separators, the articles, the capital letters, polysemy, barbarisms, prepositions and general mistakes. The analysis is based on specific examples.

Motivación en Psicología y salud: motivación no es sinónimo de intención, actitud o percepción de riesgo / Motivation in health Psychology: motivation is not synonymous of intention, attitude or risk perception

Se revisa el uso del concepto de motivación en Psicología y salud. Se concluye que algunas teorías hacen un uso incorrecto del concepto, pues incurren en lo que Ryle llamó errores categoriales, lo cual compromete la interpretación que se hace de los resultados obtenidos en la práctica de la investigación.

It's review the motivation concept uses in health psychology. It's conclude that some theories make an incorrect concept uses, to commiting which Ryle's name as categorial mistakes, compromising the interpretation of the results gained in the research practice.

Errores o equivocaciones por acción u omisión en acciones de promoción y prevención dirigidas a gestantes en Manizales, 2007 / Erros ou equivocos por ação ou omissão em ações de promoção dirigida a gestantes em Manizales, 2007 / Errors and mistakes due to action or omission in promotional and preventional actions directed to pregnant mothers in Manizales, 2007

El propósito del presente trabajo es mostrar los resultados de la investigación sobre errores y equivocaciones por acción u omisión en acciones de promoción y prevención dirigidas a gestantes en Manizales realizada durante el año 2007. El estudio realizado fue de tipo descriptivo retrospectivo y evaluativo. Éste se llevó a cabo con usuarios de los programas de promoción y prevención y profesionales responsables de dicho programa; la muestra de los usuarios a encuestar se determinó mediante un muestreo aleatorio simple con una confianza del 95% y un error del 5%, y la de los profesionales se realizó a conveniencia tendiendo en cuenta quiénes realizaban los controles o consultas. Se aplicó una entrevista individual. Se analizó en Epiinfo 2002 y SPSS. Entre los resultados, queremos mencionar que los errores y equivocaciones más frecuentes por parte de los usuarios fueron inasistencia a actividades propias del programa, automedicación y escaso cumplimiento de recomendaciones de autocuidado; entre los errores y equivocaciones por parte de los profesionales se resaltan falta de interrogatorio, no seguimiento a inasistentes, escasas explicaciones durante el control o la consulta y omisión de exámenes paraclínicos; también se identificaron errores en el sistema relacionados con falta de oportunidad en la entrega de medicamentos y en la asignación de citas

The purpose of this paper is to show the research results on the errors and mistakes due to action or omission in promotion and prevention aimed at pregnant mothers in Manizales in 2007. It was a retrospective, descriptive and evaluative study, that was carried out with users of promotion and prevention programs, and the responsible professionals of these programs. The sample of users was determined with a random sample, with a confidence margin of 95% and a margin error of 5%. The sample of the professionals was conducted in concordance with the people who were in charge of the check-ups or consultations. Individual interviews were carried out, with the data being analyzed with Epiinfo 2002 and SPSS. Among the results, we would like to mention that the most frequent errors and mistakes by users had been the absence in program activities, self-medication and not thoroughly following medical indications. The most relevant professional mistakes include few questions regarding the patients’ clinical history; not following-up on absent patients; few explanations on the importance of controls, and omission of paraclinical exams. Errors in the system regarding convenient medicine delivery and in the assignment of medical appointments were also identified

O propósito da presente pesquisa é apresentar os resultados da averiguação sobre erros e equivocos por ação ou omissão em ações de promoção e prevenção dirigidas a gestantes em Manizales feitas durante o ano 2007. A pesquisa realizada foi de tipo descritivo retrospectivo e de avaliação. A pesquisa foi realizada com usuários dos programas de promoção e prevenção e profissionais responsáveis de programa, a amostra de usuários a serem visitadas foi determinada por uma amostra aleatória simples com uma confiança de 95% e 5% de erro, e profissionais foi realizada por conveniência tendo em conta que realizou as inspeções ou consultas. Aplicamos uma única entrevista. Foram analisados no EpiInfo 2002 e SPSS. Entre os resultados, podemos dizer que os erros mais comuns e erros por parte dos usuários eram não-comparecimento às atividades do programa, a auto-medicação e má aderência com recomendações de auto-atendimento, entre os erros e os erros por falta de interrogatório destaques profissionais, no seguimento aos faltosos explicação, insuficiente para a supervisão ou consulta e falta de exames laboratoriais; erros do sistema identificou também relacionadas com a falta de pontualidade na entrega de medicamentos e agendamento.

¿Podemos aprender de los errores del pasado? / Can we learn from errors of the past?

Los errores médicos cometidos durante las etapas de diagnóstico y tratamiento de las enfermedades, son en cierta forma inherentes a la práctica de la medicina pero necesitan ser disminuidos constantemente. Es habitual considerar al médico como único responsable de estos errores, la mayoría de los cuales se cometen actualmente durante el proceso de introducción y difusión de nuevas tecnologías. Con el presente artículo se trata de recordar a los médicos los procesos mediante los cuales las nuevas tecnologías llegan a formar parte de la práctica médica habitual y como frecuentemente el médico responsable del enfermo, no ha sido quien directamente introdujera e impulsara la tecnología utilizada. Al poner en conocimiento de los médicos las observaciones realizadas sobre la historia de las diferentes etapas por las que pasa toda innovación en medicina, se le da la posibilidad de conocer la responsabilidad que le corresponde cunado se produce un error médico. También se hace énfasis en el imprescindible escrutinio científico, y en la necesaria evaluación tecnológica periódica de todos los procedimientos que forman parte de la práctica médica.

The medical mistakes made during the stages of diagnosis and treatment of the diseases are in a certain way inherent to medical practice, but they need to be constantly reduced. It is usual to consider the physician as the unique responsible for these mistakes, most of which are made at present during the process of introduction and spreading of new technologies. In this article, an attempt is made to remind the doctors the processes by which the new technologies are incorporated to habitual medical practice and how frequently the doctor responsible for the patient is not the one who directly introduces or impulses the technology used. On informing the doctors about the observations carried out on the history of the different stages every innovation in medicine pass through, they have the possibility to know their responsibility when a medical mistake is made. Emphasis is also given to the indispensable scientific scrutiny, and to the necessary periodical technological evaluation of all the procedures being part of medical practice.

Taking Comprehensive Precautionary Measures to Reduce Drug Dispensing Mistakes and the Hidden Dan?gers in Outpatient Dispensary / 中国药房

OBJECTIVE:To reduce drug dispensing mistakes and the hidden dangers in outpatient dispensary so as to improve the quality of drug dispensing.METHODS:The corresponding intervention measures were taken based on the analysis on drug dispensing mistakes and the hidden dangers in outpatient dispensary,meanwhile the state after intervention was compared with that before.RESULTS:The drug dispensing mistakes decreased from40cases to16cases with the decreasing rate at60%after intervention;and the hidden dangers of mistakes has decreased from178cases to118cases with the decrease rate at33.7%.CONCLUSION:The drug dispensing mistakes and the hidden dangers in outpatient dispensary have been de?creased effectively and the quality of drug dispensing has been improved through the practice of the comprehensive precau?tionary measures.

Ocorrências éticas na enfermagem / Negligence: a risk factor in caring / Negligencia: factor de riesgo del cuidar

Este estudo utiliza cento e catorze registros de ocorrências éticas levantadas por uma Comissão de Ética de Enfermagem de um hospital do Município de São Paulo, no período de 1995 a 2001. Os objetivos foram: caracterizar os profissionais de enfermagem envolvidos e identificar as causas das ocorrências. Utilizou-se como instrumento uma ficha previamente elaborada. Os resultados: a maioria das ocorrências foi praticada por pessoas do sexo feminino, da faixa etária de 30 a 39 anos. Os auxiliares de enfermagem foram responsáveis pelo índice mais expressivo de ocorrências éticas. Destacou-se a negligência como principal causa das ocorrências, seguida pelas imprudência e a imperícia. O tipo de falha mais freqüente foi o erro no preparo e administração de medicamentos.

Descriptive and exploratory study with a quantitative approach involving hundred fourteen causes of nursing ethical occurences (or infractions) between 1995 _ 2001. The objectives of the study were to: 1) characterize the nursing professionals involved in ethical occurences; 2) identify causes of mistakes made. Outcomes obtained showed that: a) nursing auxiliaries were responsible for the majority of ethical occurences; b) the main cause of occurrences were negligence, followed by imprudence; c) the more frequent technical mistake observed was in the preparation and/or administration of medicines. This study aims to contribute for a better understanding of the ethical issue involved in the daily nursing practice, as well as to alert profissionals in order to not be involved in similar ethical events.

Estúdio descriptivo y exploratório com abordaje cuantitativo envolviendo ciento y catorce causas de ocurrencias éticas (o infracciones) entre 1995-2001. Los objectivos del estúdio fueron: 1) caracterizar los profesionales de enfermería envolvidos em ocurrencias éticas; 2) identificar las causas prevalientes de errores cuanto a la categoria de profisional y su jornada de trabajo. Resultados obtenidos demostraron que: a) los auxiliares de enfermería eran responsables por la mayoria de lãs ocurrencias éticas; b) la causa principal de ocurrencias era la negligencia, seguida por imprudencia; c) los errores técnicos más observados eran em la preparación y/o administración de medicinas. Este estúdio visa contribuir para la mejor comprensión de las cuestiones éticas que envolven la prática diária de enfermería y alertar los profesionales para que no incurran em eventos de esta naturaleza.

On the Fear of Mistakes and Failures and the Creative Development of College Student / 中华医学教育探索杂志

The “fear of mistakes and failures” is the psychological state of being scared by the potential mistakes and failures,and therefore dare not to try and explore.This kind of fear is extremely harmful to the creative development of college students.The college students' “fear of mistakes and failures” can be caused by a lot of social issues.The paper is intended to analyze this kind of psychological phenomenon and then put forward the countermeasures to get rid of it.

Estudo sobre ocorrências éticas com pessoal de enfermagem de um hospital na cidade de São Paulo / Study on ethical occurrences involvery staff of a hospital in São Paulo city (Brasil)

Trata-se de um estudo descritivo, exploratório e de abordagem quantitativa, em que foram utilizadas as sugestões metodológicas de Gil(1994), Duverger (1962), Goode & Hatt (1997) e Kerlinger (1980). Nessa pesquisa, foram utilizados cento e catorze registros de ocorrências (infrações) éticas levantadas pela comissão de ética de enfermagem da instituição, campo do estudo, no período de 1995 a 2001. Os objetivos foram: 1) caracterizar os profissionais de enfermagem envolvidos em ocorrências éticas; 2) identificar as falhas cometidas, as causas de erros, as providências tomadas e casos de reincidências; 3) correlacionar as falhas com as características dos profissionais envolvidos. O instrumento para a coleta de dados foi uma ficha especialmente preparada. Resultados: 1) a maioria das ocorrências éticas foi praticada por pessoas do sexo feminino, da faixa etária predominante de 30 a 39 anos. 2) Os auxiliares de enfermagem foram responsáveis pelo índice mais expressivo de ocorrências éticas. 3) Detectou-se maior incidência de erros durante o dia. 4) A principal causa de ocorrências foi a negligência, seguida da imprudência, imperícia, indução ao erro e omissão. 5) O tipo de falha técnica mais freqüentemente observado foi o erro no preparo e/ou administração de medicamentos. Este estudo, longe de haver esgotado as questões éticas que permeiam a prática de enfermagem, visa contribuir para a compreensão dessas questões que envolvem a prática cotidiana de enfermagem e alertar os profissionais para previnir eventos dessa natureza.

This is a descriptive and exploratory paper using a quantitative approach. Methodological suggestions were taken from Gil (1994), Duverger(1962), Goode& Halt (1997) and Kerliner(1980). In this research, hundred fourteen cases of nursing ethical occurences (or infractions) between 1995-2001. These cases were identified and recorded by the Nursing Ethical comitte. Objetives of the study coere: 1) to charaterize the nursing professionals involved in ethical occurences; 2) to identify mistakes made and measures takend as well as possible cases of reincidences; 3) to correlate mistakes and occurrences with the involved staff members characteristics. A special paper was used as instrument for collection of data. Results obtained showed that: 1) most of the ethical occurences was practiced by women and the predominant age group of those involved was from 30 to 39 years. 2) the nursing auxiliaries were responsable for the majority of ethical occurences. 3) Very large incidence of mistakes occurred during the day. 4) the main causes of occurences were negligence, followed by imprudence, inability, induction to mistake and omission. 5) the more frequent technical mistake observed was in the preparation an/or administration of medicines. This research, far away from having done a complete study, has just opened a view about the ethical issures that permeate the nursing practice. Its aim is also to contribute for a better understanding of the ethical issues involved in the daily nursing practice, as well as to alert profesionals in order to not be involved in similar ethical events.