[e-farmacos] BMJ: articulos sobre 'seguridad del paciente'

["Madurga, Mariano" <mmadurga@agemed.es>]

Estimadas y estimados amigos,

Acaba de salir el ultimo numero del BMJ, del dia 13 de enero de 2007. 

Entre otras primicias, destaco los dos Editoriales (local y de USA) y los diferentes articulos que se reunen sobre el tema emergente de la seguridad del paciente y los metodos de notificacion de incidentes adversos, relacionados con medicamentos o con otras intervenciones sanitarias. A la vista de las experiencias actuales y de la situacion de crisis de recursos que presenta el NHS britanico, y de los cambios de la FDA en la linea reciente.
 
Este resumen con los 2 editoriales reunen las direcciones del resto de articulos que se comentan:

Saturday 13 January 2007
http://bmj.com/cgi/content/full/334/7584/0 http://bmj.com/cgi/content/full/334/7584/0-a 

Editor's Choice

Routine reporting 
Fiona Godlee, editor 
fgodlee@bmj.com <mailto:fgodlee@bmj.com>  

UK health care is suffering from what Will Hutton calls the "delivery paradox" (doi: 10.1136/bmj.39080.574699.47). Although standards of care are improving, public satisfaction is falling. This is important, says Hutton, because public dissatisfaction threatens could support for the universal public delivery of health care, which is fundamental to the NHS. 

What's to be done? Hutton's solution won't suit everyone. It's called distributive democracy and goes completely counter to the current tide in the UK towards ever greater centralisation (despite the government's rhetoric of decentralisation). Hutton argues that general elections and party democracy can't respond to users' needs at a local level or on a day to day basis. Instead he advocates making our public institutions as responsive to citizens as the best private companies are to their customers. Health care should, he says, follow the BBC's lead in applying a "public value" test for everything it does. Clinical judgments about best value won't always coincide with public preferences-the furores over Herceptin and treatments for Alzheimer's disease demonstrated that. But Hutton argues that these tensions exist anyway and are better confronted in open debate. 

I hope Brown and Cameron are listening. One or other of them will be in charge quite soon, and this sounds better than the current way of doing things, even if the practicalities have yet to be worked out. A draft report says that a further 37 000 jobs will go in the NHS in the next two years in an attempt to stem the financial crisis (doi: 10.1136/bmj.39090.709803.4E). Cuts on this scale and at this pace cannot possibly respond to strategic or local need. Nor can it be good for patient safety. Katherine Teale reports a crisis of care on the wards caused by lack of trained staff and continuity of care (doi: 10.1136/bmj.39063.450243.47). 

Sadly, money spent on trying to improve patient safety by encouraging people to report potentially harmful incidents may have been wasted. Sari and colleagues (doi: 10.1136/bmj.39031.507153.AE) found that routine incident reporting performed poorly compared with case note review. Time constraints and fear of shame, blame, or litigation are likely contributors, they say. Charles Vincent (doi: 10.1136/bmj.39071.441609.80) urges greater clarity about the purpose of voluntary reporting. It must be to learn from mistakes and can tell us nothing about how often mistakes occur. 

The BMJ's routine reporting system suffers from the same flaws. It can't tell us how many readers approve of the new look BMJ and how many don't, but it is giving us a fair idea. And the verdict (via rapid responses and emails direct to the BMJ's offices) has been overwhelmingly positive. Many readers have told us that they read more of the first new issue than they had ever done before, which is what we had hoped for. Even Richard Lehman, who was less than complimentary about the last redesign, expresses modified rapture in his journal blog (http://blogs.bmj.com/category/comment/medical-journals-review). (You might also like to read about his "Nightmare on NEJM Street" in this week's BMJ doi: (10.1136/bmj.39091.590093.47)). We haven't pleased everyone. Some readers preferred it the way it was, especially those who still hanker after the old blue cover with the contents on it. I have to say, though, that the BMJ won't be returning to that any time soon. But please keep the feedback coming. 


Editor's Choice
US editor's choice 
Safety at what cost? 
Douglas Kamerow, US editor dkamerow@bmj.com 

Improving patient safety is a complicated business. Sometimes we don't know exactly what to do. Other times we must balance increased safety with decreased patient autonomy or slowed availability of possibly life-saving medications. We have examples of all of these in this week's BMJ. 

In response to patient safety concerns many hospitals have set up routine incident reporting systems. Ali Sari and colleagues reviewed the results of such a system in a large hospital and compared them to a structured review of case notes for the same 1000 admissions. Their study (doi: 10.1136/bmj.39031.507153.AE) found that the incident reporting system missed almost half of the important patients safety incidents-those that actually resulted in patients being harmed. In an accompanying editorial (doi: 10.1136/bmj.39071.441609.80), Charles Vincent agrees that reporting systems are not an effective way to improve patient safety. He argues that only active measurement and improvement programs focused on known high-risk activities will me aningfully decrease the risks of adverse events. 

Falls are the most common adverse event in hospitals and nursing homes and often lead to injury and subsequent functional impairment. David Oliver et al performed a systematic review (doi: 10.1136/bmj.39049.706493.55) of strategies to decrease falls in these settings. They found evidence that comprehensive hospital fall prevention programs lead to a modest reduction in hip fracture rates and that hip protectors help prevent hip fractures in nursing homes. Ian Cameron and Susan Kurrle comment (doi: 10.1136/bmj.39084.388553.80) that most research on fall prevention has been done in the community and less is known about institutional settings. Hospital and nursing home patients are generally frailer and have a higher prevalence of dementia, both risk factors for falls. How to best prevent falls in institutional settings is still largely an unanswered question. 

Finally, Linda Horton comments (doi: 10.1136/bmj.39049.545880.BE) on an Institute of Medicine report on the US Food and Drug Administration. She advocates increased FDA funding, enlarged focus on postmarketing safety studies, and increased international collaboration to improve the drug approval process. But no drugs are completely without risk. Faster, earlier drug approvals will undoubtedly lead to the discovery of some of those risks after drugs have been approved and marketed. 

Un fuerte abrazo,

Mariano Madurga Sanz
Jefe de Servicio de Coordinacion del SEFV
Division de Farmacoepidemiologia y Farmacovigilancia
Agencia Espanhola de Medicamentos y Productos Sanitarios
E-28022-Madrid
(Espanha)
Correo-e: mmadurga@agemed.es