Comparación de dos métodos de detección de posibles efectos adversos intrahospitalarios / No disponible

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Beyond "see one, do one, teach one": toward a different training paradigm.

In the process of acquiring new skills, physicians-in-training may expose patients to harm because they lack the required experience, knowledge and technical skills. Yet, most teaching hospitals use inexperienced residents to care for high-acuity patients in complex and dynamic environments and provide limited supervision from experienced clinicians. Multiple efforts in the last few years have started to address the problem of patient safety. Examples include voluntary incident-reporting systems and team training workshops for practising clinicians. Fewer efforts have addressed the deficits in training new physicians, especially related to knowledge, skills and competence. The current apprenticeship or "see one, do one, teach one" model is insufficient because trainees learn by practising on real patients, which is particularly an issue when performing procedures. Residents have expressed that they do not feel adequately trained to perform procedures safely by themselves. In this paper, we conduct an informal review of the impact of current training methods on patient safety. In addition, we propose a new training paradigm that integrates competency-based knowledge and clinical skills, with deliberate attitudinal and behavioural changes focused on patient safety in a safe medically simulated environment. We do so with the hope of creating a better marriage between the missions of training and patient safety.

Beyond "see one, do one, teach one": toward a different training paradigm.

In the process of acquiring new skills, physicians-in-training may expose patients to harm because they lack the required experience, knowledge and technical skills. Yet, most teaching hospitals use inexperienced residents to care for high-acuity patients in complex and dynamic environments and provide limited supervision from experienced clinicians. Multiple efforts in the last few years have started to address the problem of patient safety. Examples include voluntary incident-reporting systems and team training workshops for practising clinicians. Fewer efforts have addressed the deficits in training new physicians, especially related to knowledge, skills and competence. The current apprenticeship or "see one, do one, teach one" model is insufficient because trainees learn by practising on real patients, which is particularly an issue when performing procedures. Residents have expressed that they do not feel adequately trained to perform procedures safely by themselves. In this paper, we conduct an informal review of the impact of current training methods on patient safety. In addition, we propose a new training paradigm that integrates competency-based knowledge and clinical skills, with deliberate attitudinal and behavioural changes focused on patient safety in a safe medically simulated environment. We do so with the hope of creating a better marriage between the missions of training and patient safety.

[Late mediastinitis with bilateral hydrothorax after vessel perforation by a central venous catheter]. / Mediastinitis tardía con hidrotórax bilateral tras perforación vascular por catéter venoso central.

A central venous catheter was inserted into the right internal jugular vein of a 67-year-old woman to provide parenteral nutrition on the 7th day after surgery. Five days later, mediastinitis with bilateral hydrothorax had developed and was causing respiratory failure and systemic inflammatory response syndrome secondary to documented vascular perforation by the catheter. Four factors have been associated with increased risk of perforation: catheter rigidity and diameter, the angle between the tip of the catheter and the vessel wall, and insertion from the left. Three catheter positions have been described as safe when radiologically confirmed: the superior vena cava, the point where the superior vena cava meets the atrium, and the midpoint of the innominate vein. However, it should not be forgotten that a radiograph is 2-dimensional and a single image of a catheter tip can correspond to a variety of locations (superior vena cava, vena innominata, extravascular location, and more). Even when there is clinical and radiologic evidence of catheter positioning, vascular perforation should be suspected in patients with a central venous catheter and bilateral pleural effusion who present respiratory insufficiency and hemodynamic instability.

Importancia de una descripción detallada de todo incidente crítico / Importance of giving a detailed description of all critical events

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Block of the N-methyl-D-aspartate receptor by phencyclidine-like drugs is influenced by alternative splicing.

N-Methyl-D-aspartate (NMDA) receptors were expressed in Xenopus oocytes from injected mRNA. The presence of an alternatively-spliced insertion encoding 21 amino acids at the N-terminus of the NMDAR1 (NR1(111)) subunit, made homomeric assemblies of the receptor more sensitive to ketamine and MK-801 than receptors assembled from NMDAR1 subunits lacking this insert (NR1(011) and NR1(001)). The influence of this insert was maintained when NR1 subunits were co-expressed in heteromeric combinations with NR2B. The increased sensitivity of the receptors containing the insert (NR1(111)) was accompanied by a faster on-rate for drug action than was observed for receptors lacking the insert (NR1(011) and NR1(001)). Our results suggest that the action of phencyclidine-like drugs is influenced by the presence of Insertion I in the NMDA isoforms, generated by alternative splicing.