Errores de medicamentos LASA en anestesiología en Uruguay
Resumen
El error en la administración de fármacos es una causa frecuente de incidentes críticos en el perioperatorio. Se definen como medicamentos LASA (del inglés, look alike, sound alike) a aquellos medicamentos que se parecen físicamente o que sus nombres suenan parecido.
Objetivo: conocer la situación de probable riesgo a la que se exponen los pacientes en Uruguay durante las cirugías con anestesia a causa de errores de medicación LASA (subgrupo LA).
Material y método: se documentaron fotográficamente las ampollas involucradas en las confusiones con medicamentos LASA de uso anestésico que causaron o pudieron causar la muerte del paciente al inyectarse accidentalmente. La identificación de las ampollas confundidas se realizó mediante una encuesta anónima a una muestra representativa de los anestesiólogos de Uruguay (n=70). Se analizaron dos tipos de confusiones: las casi inyecciones y las inyecciones accidentales.
Resultados: el atracurio es el fármaco que se confunde con mayor frecuencia; los 10 fármacos más confundidos (27,0% de los 37 analizados) están implicados en 80,6% de las confusiones y en 88,4% de las inyecciones accidentales. Se fotografiaron las ampollas LASA para esos 10 fármacos y 48 de los 56 pares de fármacos confundidos.
Conclusión: en Uruguay existen ampollas LASA de uso anestésico que generan riesgo potencial y real de confusiones, dado su aspecto similar, al 86,2% de los anestesiólogos. El 88,4% de esos accidentes podrían disminuirse si se identifican claramente las ampollas de 10 fármacos.
Citas
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