AHRQ: Discusión de casos clínicos de situaciones con compromiso de la seguridad del paciente en Urgencias

La AHRQ presenta casos clínicos sobre diversas situaciones donde existe compromiso de la seguridad del paciente, con discusión y estrategias de mejora.

RECOMENDADO: http://www.webmm.ahrq.gov/caseArchive.aspx#16 .

A continuación un extracto de los casos presentados en marzo/08

Los problemas en la transmisión de información sobre el historial del paciente entre diferentes servicios o niveles asistenciales o en el mismo servicio de urgencias.... el riesgo de las interrupciones por una simple llamada... casos clínicos con discusión presentado en la página de la Agency for HealthCare Research and Quality (AHRQ) (http://www.webmm.ahrq.gov/case.aspx?caseID=194) :

"A fatigued emergency department (ED) physician was coming to the end of his long shift when he was told there was a patient referral from an area nursing home. When he picked up the phone, the nursing home physician on the line started to explain, "I'm sending you a 68-year-old man with a history of interstitial lung disease who has been having some shortness of breath." At that moment, the call was interrupted as a senior nurse grabbed the ED physician and said, "We need you in code room one now!" The paramedics had just arrived in the ED with a critically ill patient. .....................

........................The scenario faced by this emergency physician is all too common—because of lapses in communication, he was forced to make crucial medical decisions with little information. In this case, communication failures occurred between the nursing home and the ED as well as between emergency medical services (EMS) personnel and the ED. This case provides an opportunity to explore these critical transitions in care.

............... The 2008 Joint Commission Patient Safety Goal 2E requires all health care providers to "implement a standardized approach to handoff communications" (6) and states that the organization's process for effective handoff communication ought to include (7):
Interactive communication allowing opportunities for questions between the giver and receiver of patient information.
Up-to-date information regarding patient condition, care, treatment, medications, services, and recent or anticipated changes.
Methods to verify received information, including repeat-back or read-back techniques.
Opportunities for the receiver to review relevant patient historical data, which may include previous care, treatment, or services.
Limited interruptions to minimize the possibility that information fails to be conveyed or is forgotten