Campanha do Passo 1: Anestesia e Prevencao de Infeccoes do Programa "10 PASSOS PARA A ANESTESIA SEGURA", elaborada pelo Comite de Qualidade e Seguranca dos Servicos Medicos de Anestesia (SMA) de Sao Paulo. Karen C. Nanji, Amit Patel, Sofia Shaikh, Diane L. Seger, David W. BatesAnesthesiology 2016; 124:25-34ABSTRACTBackground: The purpose of this study is to assess the rates of perioperative medication errors (MEs) and adverse drug events (ADEs) as percentages of medication administrations, to evaluate their root causes, and to formulate targeted solutions to prevent them.Methods: In this prospective observational study, anesthesia-trained study staff (anesthesiologists/nurse anesthetists) observed randomly selected operations at a 1,046-bed tertiary care academic medical center to identify MEs and ADEs over 8 months. Retrospective chart abstraction was performed to flag events that were missed by observation. All events subsequently underwent review by two independent reviewers. Primary outcomes were the incidence of MEs and ADEs.Results: A total of 277 operations were observed with 3,671 medication administrations of which 193 (5.3%; 95% CI, 4.5 to 6.0) involved a ME and/or ADE. Of these, 153 (79.3%) were preventable and 40 (20.7%) were nonpreventable. The events included 153 (79.3%) errors and 91 (47.2%) ADEs. Although 32 (20.9%) of the errors had little potential for harm, 51 (33.3%) led to an observed ADE and an additional 70 (45.8%) had the potential for patient harm. Of the 153 errors, 99 (64.7%) were serious, 51 (33.3%) were significant, and 3 (2.0%) were life-threatening.Conclusions: One in 20 perioperative medication administrations included an ME and/or ADE. More than one third of the MEs led to observed ADEs, and the remaining two thirds had the potential for harm. These rates are markedly higher than those reported by retrospective surveys. Specific solutions exist that have the potential to decrease the incidence of perioperative MEs.Caso queira, deixe seu e-mail nos comentarios abaixo desta postagem ou solicite pelo e-mail anestesiasegura@sma.com.br e lhe enviaremos o artigo completo. A prospective randomised controlled trialGeorge Thomas-Kattappurathu, Ananth Kasisomayajula and Judith ShortBACKGROUND: There is a wide variation in clinical practice amongst clinicians in the process of removal of the laryngeal mask airway (LMA) in children. Some of the airway complications during recovery are associated with the position of the child as well as the depth of anaesthesia and are potentially avoidable.OBJECTIVES: We wished to determine whether removal of the LMA in the lateral position reduces the incidence of airway complications, either in a deep plane of anaesthesia or awake.DESIGN: A prospective randomised trial.SETTING: A tertiary childrens hospital.PATIENTS: The study population comprised 216 American Society of Anesthesiologists (ASA) 1 to 2 patients aged 1 to 16 years scheduled for elective surgery under general anaesthesia using an LMA. Exclusion criteria were children less than 1 year old, ASA 3 or above, presence of congenital heart disease or gastro-oesophageal reflux, anticipated difficult airway and patients undergoing airway or dental surgery.INTERVENTION: We randomly allocated 212 children into one of four groups for LMA removal, deeply anaesthetised or awake in either the lateral or supine position. Various airway complications were recorded after removal of the LMA.MAIN OUTCOME MEASURES: The primary outcome measure