P1554TYPES OF INCIDENTS MANAGED AT TWO DIFFERENT MEDICAL LEVELS IN A LARGE MULTINATIONAL RENAL SERVICES PROVIDER NETWORK

2020 ◽  
Vol 35 (Supplement_3) ◽  
Author(s):  
Belén Marrón ◽  
Israel Silva ◽  
Carlos Lucas ◽  
Marietta Torok ◽  
Charlotta Wollheim ◽  
...  
Keyword(s):  
Air Embolism ◽  
Unexpected Death ◽  
Power Failure ◽  
Country Level ◽  
Provider Network ◽  
Health Authorities ◽  
Timely Feedback ◽  
Severe Hypotension ◽  
Life Threatening ◽  
Corporate Office

Abstract Background and Aims Patient safety programs need a well-structured organization to facilitate proactive and fair reporting, prompt evaluation analysis and timely feedback followed by measure implementation and auditing. To analyze all types of incidents in our network from Jan.1st to Sept. 30th, 2019 by two different levels (Corporate and Country) of medical management alert. Method Our institution has tracked all incidents under a structured process program for the last 10 years, according to 4 incident types (Patient related, Staff-visitors, Products and Equipment) and 54 subcodes. Incidents are considered as serious when they may be life-threatening or result in death, impaired body function/structure and/or are deemed serious based on appropriate medical judgment. Communication to Health Authorities applies in accordance with local country regulations. “Serious incidents” are immediately notified to the Corporate Office and to each Country Medical lead, whilst different codes may generate alerts into Corporate or Country. Results A total of 68.399 incidents (2.7 incident/patient/year) were reported during Q1-Q3 2019. Total incidents/1000 treatments were 17.1 (12.1 were patients related incidents). Causes for alerts at corporate level (n=65) were: cardiorespiratory arrest (28%); unexpected death (15%); seroconversion (9%); hemolysis (8%), severe hypotension (6%) and air embolism (3%). Reported incidents at country level (n=655) were almost half ascribed to equipment [water supply, power failure and flooding (41%)], medication errors (36%), venous needle dislodgment (19%) and Injuries (3%). Conclusion Despite continuous efforts to get better results, there is room for improvement on better staff compliance with our standard operating procedures especially regarding medications and venous needle dislodgment risk assessment.

scholarly journals Asymptomatic mediastinal extra-adrenal paraganglioma as a cause of sudden death: a case Report

2019 ◽  
Vol 14 (1) ◽  
pp. 564-567
Author(s):  
Qiancheng Xu ◽  
Yingya Cao ◽  
Hongzhen Yin ◽  
Rongrong Wu ◽  
Tao Yu ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Case Report ◽  
Respiratory Failure ◽  
Pressure Drop ◽  
Thoracic Cavity ◽  
Severe Hypotension ◽  
Life Threatening ◽  
History Of ◽  
Posterior Mediastinal ◽  
Extra Adrenal Paraganglioma

AbstractA 23-year-old female patient was referred for treatment of a posterior mediastinal tumour. There was no history of hypertension or headache and no other complaints. The patient’s blood pressure increased to 210/125 mmHg after surgically manipulating the tumour, subsequently reversing to severe hypotension (25/15 mmHg) immediately after the tumour was removed. The life-threatening and irreversible blood pressure drop was difficult to treat with fluid and vasopressors, and the patient ultimately died of cardio-respiratory failure. Asymptomatic paraganglioma can be non-functional but can also be fatal. For any lump in the thoracic cavity, paraganglioma should be ruled out.

scholarly journals Multidisciplinary Approach to Suspected Sudden Death Caused by Arteriovenous Malformation Rupture: A Case Report

Medicina ◽  
2021 ◽  
Vol 57 (7) ◽  
pp. 644
Author(s):  
Federico Giuseppe Patanè ◽  
Massimiliano Esposito ◽  
Andrea Giovanni Musumeci ◽  
Monica Palermo ◽  
Marco Torrisi ◽  
...  
Keyword(s):  
Arteriovenous Malformation ◽  
Cause Of Death ◽  
Venous Malformation ◽  
Healthy Woman ◽  
Unexpected Death ◽  
Medical Problems ◽  
Variable Diameter ◽  
Life Threatening ◽  
Brain Avms ◽  
The Brain

Arteriovenous malformations (AVMs) are rare congenital conditions with a prevalence of less than 1% and are mostly asymptomatic. However, these malformations can suddenly cause intense pain or bleeding, leading to life-threatening medical problems. This report presents a case of an unexpected death in a 37-year-old previously healthy woman due to an intra-cerebellum arteriovenous malformation rupture identified during autopsy. While infective processes where preliminarily excluded, a Post Mortem Computed Tomography (PMCT) identified a tetra ventricular hemorrhage and intra-cerebellum hemorrhage. Toxicological examination was negative for most substances of abuse. During autopsy an intense hemorrhagic infiltrate in the subarachnoid space was observed. After formalin fixation of the brain the cerebellum showed hemorrhagic infarction on fourth ventricle sides, as well as several small reddish infarctions across the entire cerebellum parenchyma. Histological examination of the brain and cerebellum showed a suffusion of erythrocytes in the sub-arachnoid region. Evidence of an arterio-venous malformation, with several intertwine vessels of variable diameter, surrounded by hemorrhagic evidence. The autopsy played a crucial role in identifying the location and the possibly affected vessel, as well as defining the cause of death. It is necessary to have a greater number of autopsies to make an epidemiological contribution. Furthermore, it is crucial to create a multicenter data network with other authors from other departments to improve information about epidemiological, clinical, diagnostic and therapeutic data. Most brain AVMs as cause of death are often undiscovered.

Metabolic disease in 10 patients with sudden unexpected death in infancy or acute life-threatening events

2015 ◽  
Vol 57 (3) ◽  
pp. 348-353 ◽  
Author(s):  
Tomoo Takahashi ◽  
Kenji Yamada ◽  
Hironori Kobayashi ◽  
Yuki Hasegawa ◽  
Takeshi Taketani ◽  
...  
Keyword(s):  
Metabolic Disease ◽  
Sudden Unexpected Death ◽  
Unexpected Death ◽  
Life Threatening

scholarly journals Head-down tilt position successfully prevent severe brain air embolism

2018 ◽  
Vol 6 ◽  
pp. 2050313X1880926 ◽  
Author(s):  
Gaku Yamaguchi ◽  
Hiroyuki Miura ◽  
Eiji Nakajima ◽  
Norihiko Ikeda
Keyword(s):  
Cardiac Arrest ◽  
Low Temperature ◽  
Brain Damage ◽  
Air Embolism ◽  
Cardiac Massage ◽  
Open Chest ◽  
Successful Recovery ◽  
Life Threatening ◽  
Margin Detection ◽  
Air Embolus

Air embolisms are rare life-threatening complications that develop under various conditions, including surgery. During segmentectomy for thoracic surgery, air is blown into the selected bronchus for segment margin detection. This may result in the formation of an air embolus. Herein, we report a case of successful recovery from sudden intraoperative cardiac arrest due to an air embolism in a patient undergoing left superior division segmentectomy via open thoracotomy. Intraoperatively, the patient was positioned head-down. Upon blowing air into the bronchus, the patient suddenly developed cardiac arrest. Open-chest cardiac massage and low-temperature therapy were commenced and the patient recovered. The head-down position prevents the air embolus from reaching the brain and thus prevents severe brain damage, whereas continuous open-chest massage and low temperature prevents severe body damage from anticipated cardiac air embolism. Thus, operation in the head-down position is useful in preventing severe brain damage from brain air embolisms.

scholarly journals Mayaro virus in Latin America and the Caribbean

2020 ◽  
Vol 44 ◽  
pp. 1 ◽  
Author(s):  
Niloofar Ganjian ◽  
Ana Riviere-Cinnamond
Keyword(s):  
Latin America ◽  
Surveillance Systems ◽  
Journal Articles ◽  
Academic Literature ◽  
Country Level ◽  
Health Authorities ◽  
Imported Cases ◽  
The Caribbean ◽  
Mayaro Virus ◽  
Health Organization

Objectives. To assess the distribution of Mayaro virus (MAYV) in Latin America and the Caribbean and evaluate existing country-level MAYV surveillance mechanisms. Methods. Research was conducted from May 2018 through May 2019 to collect data from academic literature on Mayaro fever in Latin America and the Caribbean. PubMed, ClinicalKey, Scopus, Nature, SciELO, LILACS, and Google Scholar were searched for peer-reviewed journal articles, and data from health authorities, including the Pan American Health Organization (PAHO) and ministries of health, was also sought. MAYV-related publications published from 1954 through 2019 were screened. Publications that added to the overall understanding of MAYV, including its geographical and epidemiological distribution, were included in this report. Results. A total of 901 MAYV cases have been reported in humans in countries in Latin America and the Caribbean. Since its discovery in 1954 in Trinidad and Tobago, MAYV has been isolated from individuals living in Argentina, Bolivia, Brazil, Ecuador, French Guiana, Haiti, Mexico, Panama, Peru, and Venezuela. Of those 901 cases, 42 of them were reported exclusively by health authorities. In contrast, 843 confirmed and presumptive autochthonous cases and an additional 16 imported cases were identified in academic literature. No country-level surveillance mechanisms for MAYV were recorded in academic literature or by health authorities. Conclusions. This report demonstrates that MAYV surveillance efforts are limited in comparison to the virus’s presence in Latin America and the Caribbean, highlighting the importance of enhancing arboviral surveillance systems in the affected countries.

scholarly journals Life-threatening air embolism during ERCP

Endoscopy ◽  
2014 ◽  
Vol 46 (S 01) ◽  
pp. E250-E251 ◽  
Author(s):  
Clotilde Duburque ◽  
Erick Beaujard ◽  
Jean-Baptiste Landel ◽  
Riadh Rihani ◽  
Karim Merouani ◽  
...  
Keyword(s):  
Air Embolism ◽  
Life Threatening

scholarly journals Iatrogenic Hepatic Pneumovenogram

2011 ◽  
Vol 2011 ◽  
pp. 1-4
Author(s):  
Govarthanan Rajendiran ◽  
Sulaiman Rathore ◽  
Gurmeet Sidhu ◽  
James Catevenis
Keyword(s):  
Air Embolism ◽  
Central Line ◽  
Cor Pulmonale ◽  
Diagnostic Dilemma ◽  
Venous Air Embolism ◽  
Iatrogenic Complication ◽  
Line Placement ◽  
Venous Catheterization ◽  
Life Threatening ◽  
Appropriate Therapy

Accidental air entry during central venous catheterization is a preventable iatrogenic complication that can cause venous air embolism (VAE). Many cases of VAE are subclinical with no adverse outcome and thus go unreported. Usually, when symptoms are present, they are nonspecific, and a high index of clinical suspicion of possible VAE is required to prompt investigations and initiate appropriate therapy. Occasionally large embolism can lead to life-threatening acute cor pulmonale, asystole, sudden death, and arterial air embolism in the presence of shunt or patent foramen ovale. This paper discusses VAE during emergency central line placement and the diagnostic dilemma that it can be created in critically ill patients. All necessary precautions have to be strictly followed to prevent this iatrogenic complication.

scholarly journals Equipment Failure: An Analysis of 2000 Incident Reports

1993 ◽  
Vol 21 (5) ◽  
pp. 673-677 ◽  
Author(s):  
R. K. Webb ◽  
W. J. Russell ◽  
I. Klepper ◽  
W. B. Runciman
Keyword(s):  
New Zealand ◽  
Crisis Management ◽  
Equipment Failure ◽  
Electrical Shock ◽  
Power Failure ◽  
Management Algorithm ◽  
Life Threatening ◽  
Zealand College ◽  
Incident Reports ◽  
Warming Devices

Of the first 2000 incidents reported to the Australian Incident Monitoring Study, 177 (9%) were due to “pure” equipment failure according to pre-defined criteria. Of these 107 (60%) involved anaesthetic equipment, 42 (24%) involved monitors, 17 (10%) other theatre equipment and 11 (6%) the gas or electricity supply. Ninety-seven (55% of the 177) were potentially life-threatening; of these two-thirds would be detected by the array of monitors recommended by the Australian and New Zealand College of Anaesthetists and all but 9 of the remainder would be handled by application of the crisis management algorithm recommended elsewhere in this symposium. Of the 9 remaining, 2 were electrical shock, 3 overheating of a humidifier or blood warmer, 2 the unavailability of a spare laryngoscope and 1 the consequence of a power failure. Meticulous adherence to the equipment checking and monitoring guidelines of the Australian and New Zealand College of Anaesthetists and application of a suitable crisis management algorithm should protect the patient from potentially life-threatening equipment failure in virtually all cases except electric shock, power failure and overheating of warming devices.

scholarly journals Undiagnosed pheochromocytoma presenting as a pancreatic tumor: A case report

Open Medicine ◽  
2020 ◽  
Vol 15 (1) ◽  
pp. 103-106 ◽  
Author(s):  
Malgorzata Emilia Legocka ◽  
Sadegh Toutounchi ◽  
Ryszard Pogorzelski ◽  
Ewa Krajewska ◽  
Krzysztof Celejewski ◽  
...  
Keyword(s):  
Adrenal Gland ◽  
Surgical Complications ◽  
Intraoperative Complications ◽  
Hypertensive Crisis ◽  
Preoperative Treatment ◽  
Tumor Type ◽  
Abdominal Incision ◽  
Alpha Blockers ◽  
Severe Hypotension ◽  
Life Threatening

AbstractPheochromocytoma is a rare catecholamine-producing tumor of the adrenal gland. Patients with known pheochromocytoma undergoing surgery require preoperative treatment with alpha-blockers to reduce the risk of intraoperative complications related to catecholamine release. If undiagnosed, pheochromocytoma can lead to life-threatening surgical complications. We report the case of a patient with a suspected solid pseudopapillary neoplasm in the pancreatic tail, for whom pancreatoduodenectomy was scheduled. However, shortly after abdominal incision, hypertensive crisis developed and was followed by severe hypotension requiring intravenous vasopressors, which prompted discontinuation of the operation. Further diagnostic evaluation revealed marked elevations in urinary excretion of methylated catecholamines and suggested that the tumor was in fact a pheochromocytoma extending from the left adrenal gland. After preoperative treatment with doxazosin, the patient underwent lateral transperitoneal laparoscopic adrenalectomy, with no major complications and an uneventful postoperative course. The pathological report confirmed a diagnosis of pheochromocytoma. Due to the potential for life-threatening surgical complications in patients with pheochromocytoma not treated preoperatively with alpha-blockers, this tumor type should be included in the differential diagnosis of abdominal tumors of unknown origin.

scholarly journals Access to Controlled Medicines in Low-Income Countries: Listening to Stakeholders in the Field

2020 ◽  
pp. 002073142090674
Author(s):  
Agnes Vitry ◽  
Gilles Forte ◽  
Jason White
Keyword(s):  
Low Income ◽  
Low Income Countries ◽  
Structured Interviews ◽  
African Countries ◽  
Country Level ◽  
Written Information ◽  
Health Authorities ◽  
Psychotropic Medicines ◽  
Republic Of The Congo ◽  
International Conventions

Little is known on current practices and challenges associated with the legal trade of medicines controlled under international conventions in low-income countries. This qualitative survey involved semi-structured interviews of stakeholders engaged in the trade of controlled medicines at a global level or at a country level in 3 African countries (Uganda, Kenya, Democratic Republic of the Congo). Nine interviews were conducted, including 3 international wholesalers, 2 relief organizations, 2 procurement officers, and 2 regulatory officers. Additionally, 4 other participants provided written information. All participants consistently reported that the current process of procuring controlled medicines in compliance with international conventions was long and complex given the number of administrative steps required for obtaining export and import authorizations, which are mandatory for both narcotic and psychotropic medicines. It may be difficult or impossible to obtain import authorizations from some health authorities in low-income countries because of long delays, mistakes in forms, absence or shortage of staff, or when annual national estimates are exceeded. The complexities of the trade of controlled medicines directly contribute to the lack of access to essential controlled medicines, both narcotics and psychotropics, in low-income countries.

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