<?xml version="1.0" encoding="ISO-8859-1"?><article xmlns:mml="http://www.w3.org/1998/Math/MathML" xmlns:xlink="http://www.w3.org/1999/xlink" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance">
<front>
<journal-meta>
<journal-id>1688-1273</journal-id>
<journal-title><![CDATA[Anestesia Analgesia Reanimación]]></journal-title>
<abbrev-journal-title><![CDATA[Anest Analg Reanim]]></abbrev-journal-title>
<issn>1688-1273</issn>
<publisher>
<publisher-name><![CDATA[Sociedad de Anestesiología del Uruguay]]></publisher-name>
</publisher>
</journal-meta>
<article-meta>
<article-id>S1688-12732017000100042</article-id>
<title-group>
<article-title xml:lang="es"><![CDATA[Seguridad en anestesia: error en la administración de fármacos LASA]]></article-title>
<article-title xml:lang="en"><![CDATA[Safety in anesthesia: an error in the administration of LASA drugs]]></article-title>
<article-title xml:lang="pt"><![CDATA[Segurança na anestesia: um erro na administração de drogas LASA]]></article-title>
</title-group>
<contrib-group>
<contrib contrib-type="author">
<name>
<surname><![CDATA[Rando]]></surname>
<given-names><![CDATA[Karina]]></given-names>
</name>
<xref ref-type="aff" rid="Aff"/>
<xref ref-type="aff" rid="Aaf"/>
</contrib>
<contrib contrib-type="author">
<name>
<surname><![CDATA[Vega]]></surname>
<given-names><![CDATA[Jessica]]></given-names>
</name>
<xref ref-type="aff" rid="Aff"/>
</contrib>
<contrib contrib-type="author">
<name>
<surname><![CDATA[Castelli]]></surname>
<given-names><![CDATA[Jorge]]></given-names>
</name>
<xref ref-type="aff" rid="Aff"/>
</contrib>
<contrib contrib-type="author">
<name>
<surname><![CDATA[Zunini]]></surname>
<given-names><![CDATA[Graciela]]></given-names>
</name>
<xref ref-type="aff" rid="Aff"/>
</contrib>
<contrib contrib-type="author">
<name>
<surname><![CDATA[Baptista]]></surname>
<given-names><![CDATA[William]]></given-names>
</name>
<xref ref-type="aff" rid="Aff"/>
</contrib>
</contrib-group>
<aff id="Af1">
<institution><![CDATA[,Hospital de Clínicas. Hospital Militar Unidad Bi-Institucional de Transplante Hepático ]]></institution>
<addr-line><![CDATA[ ]]></addr-line>
</aff>
<aff id="Af2">
<institution><![CDATA[,Hospital Militar Centro Nacional Hepato-Bilio-Pancreático Unidad Docente Asistencial]]></institution>
<addr-line><![CDATA[ ]]></addr-line>
</aff>
<aff id="Af3">
<institution><![CDATA[,Universidad de la República Facultad de Medicina Departamento y Cátedra de Anestesiología]]></institution>
<addr-line><![CDATA[ ]]></addr-line>
</aff>
<pub-date pub-type="pub">
<day>00</day>
<month>06</month>
<year>2017</year>
</pub-date>
<pub-date pub-type="epub">
<day>00</day>
<month>06</month>
<year>2017</year>
</pub-date>
<volume>30</volume>
<numero>1</numero>
<fpage>42</fpage>
<lpage>61</lpage>
<copyright-statement/>
<copyright-year/>
<self-uri xlink:href="http://www.scielo.edu.uy/scielo.php?script=sci_arttext&amp;pid=S1688-12732017000100042&amp;lng=en&amp;nrm=iso"></self-uri><self-uri xlink:href="http://www.scielo.edu.uy/scielo.php?script=sci_abstract&amp;pid=S1688-12732017000100042&amp;lng=en&amp;nrm=iso"></self-uri><self-uri xlink:href="http://www.scielo.edu.uy/scielo.php?script=sci_pdf&amp;pid=S1688-12732017000100042&amp;lng=en&amp;nrm=iso"></self-uri><abstract abstract-type="short" xml:lang="es"><p><![CDATA[Resumen: La seguridad del paciente es prioritaria en el ámbito anestésico quirúrgico. El error en la administración de fármacos es una causa frecuente de incidentes críticos en el perioperatorio. Una forma de error, es la administración del medicamento equivocado debido a las presentaciones similares. El objetivo de este trabajo es la descripción de fallas en las barreras de prevención de incidentes críticos con medicamentos, en base al estudio de un caso clínico y al análisis de sus consecuencias.  Metodología : Descripción de un caso clínico y estudio sistemático de la situación de riesgo en base al análisis taxonómico del paciente, individuo, tarea, equipo humano, lugar de trabajo y organización (PITELO) sugerido por el Sistema Español de Notificación en Seguridad en Anestesia y Reanimación (SENSAR).  Resultados : Mujer sana que presentó paro respiratorio luego de la administración intravenosa de un fármaco en el postoperatorio. Se requirió 24 hs de terapia intensiva y múltiples estudios, luego de lo cual se diagnosticó un error en la administración de fármaco. La confusión se presentó con una dupla de ampollas LASA (del inglés: look-alike, sound-alike) de los fármacos atracurio y ranitidina. La documentación fotográfica evidencia la similitud y el diagrama identifica fallas latentes del sistema. Se estimaron los costos del error y se realizaron propuestas de mejora.  Discusión y conclusiones : Se evidencia una falla en las barreras de prevención de eventos adversos y en el sistema de reporte de los mismos. Es necesario incrementar la cultura de seguridad en todos los niveles del sistema: regulatorio, institucional y personal.]]></p></abstract>
<abstract abstract-type="short" xml:lang="en"><p><![CDATA[Abstract: Patient safety is a priority in the surgical anesthetic area, and errors in drug administration area frequent cause of critical incidents in the perioperative period. One type of error is the administration of the wrong medication due to similar presentations. The objective of this study is to describe the failure of barriers to prevent critical drug incidents; this is based on the study of a clinical case and an analysis of its consequences.  Methodology . Description of a clinical case and systematic study of the risk situation based on the taxonomic analysis of the patient, individual, task, human team, workplace, and organization (PITELO), as suggested by the Spanish System of Safety Notification in Anesthesia and Resuscitation (SENSAR).  Results . A healthy woman presented in respiratory arrest after the intravenous administration of a drug in the postoperative period. It took 24 hours of intensive care and multiple studies before an error in drug administration was diagnosed. The confusion was presented with a pair of LASA (look-alike, sound-alike) ampoules of atracurium and ranitidine drugs. Photographic documentation evidences the similarity of the ampoules themselves, and the diagram identifies latent system failures. The costs of the error are estimated and proposals for improvement are provided.  Discussion and Conclusions . There is evidence of a failure in the barriers to the prevention of adverse events and in the reporting system. It is necessary to increase the safety culture at all levels of the system: regulatory, institutional, and personal.]]></p></abstract>
<abstract abstract-type="short" xml:lang="pt"><p><![CDATA[Resumo: A segurança do paciente é prioritária no âmbito anestésico cirúrgico. O erro na administração de fármacos é uma causa frequente de incidentes críticos no perioperatório. Uma forma de erro é a administração de medicação errada devido a uma apresentação similar. O objetivo deste trabalho é a descrição de falhas nas barreiras de prevenção de incidentes críticos com medicamentos, em base no estudo de um caso clínico e ao análise de suas consequências.  Metodologia . Descrição de um caso clínico e estudo sistemático da situação de risco em base ao análises taxonômico do doente, tarefa, equipamento humano, lugar de trabalho e organização (PITELO) sugerido pelo Sistema Espanhol de Notificação em Segurança em Anestesia e Reanimação (SENSAR).  Resultados . Mulher sem patologia que apresentou paro respiratório a pois a administração intravenosa de um fármacos no pós-operatório. Requereu-se de 24 hs na UTI e múltiplos estudos, logo dos quais foi diagnosticado um erro na administração do fármaco. A confusão se apresentou como causa deduplas ampolas LASA (do inglês: aparência parecida com o som) dos fármacos atracurio y ranitidina. A documentação fotográfica evidencia a similitude e o diagrama identificafalhas latentes no sistema. Foram analisados os custos do erro e realizou-se propostas de melhora.  Discussão y conclusões . Evidencia-se uma falla nas barreiras de prevenção de eventos adversos e no sistema de reporte dos mesmos. É necessário incrementar a cultura de segurança em todos os níveis do sistema: regulatório, institucional e pessoal.]]></p></abstract>
<kwd-group>
<kwd lng="es"><![CDATA[Error de medicación]]></kwd>
<kwd lng="es"><![CDATA[LASA]]></kwd>
<kwd lng="es"><![CDATA[Anestesia]]></kwd>
<kwd lng="es"><![CDATA[Seguridad]]></kwd>
<kwd lng="en"><![CDATA[Medication error]]></kwd>
<kwd lng="en"><![CDATA[LASA]]></kwd>
<kwd lng="en"><![CDATA[Anesthesia]]></kwd>
<kwd lng="en"><![CDATA[Safety]]></kwd>
<kwd lng="pt"><![CDATA[Erro de medicação]]></kwd>
<kwd lng="pt"><![CDATA[LASA]]></kwd>
<kwd lng="pt"><![CDATA[Anestesia]]></kwd>
<kwd lng="pt"><![CDATA[Segurança]]></kwd>
</kwd-group>
</article-meta>
</front><back>
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