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- Title
Análisis de causa-raíz como herramienta para identificar problemas en la atención de pacientes pediátricos con leucemia linfoblástica aguda.
- Authors
Cicero-Oneto, Carlo; Zapata-Tarrés, Marta; Ortega-Ríos Velasco, Fernando; Castillo-Martínez, Daniela; Juárez-Villegas, Luis; Moreno-Espinosa, Sarbelio; Olivar-López, Víctor; Sánchez-Medina, Jerónimo; Muñoz-Hernández, Onofre; Garduño-Espinosa, Juan
- Abstract
Background: Root cause analysis is a qualitative technique characterized by a sequential order of questions to prevent errors by the acknowledgment and management of its diverse components. Acute lymphoblastic leukemia is the most common cancer in children. Due to the necessity of a multidisciplinary approach, it can be the target of diverse latent errors, which jeopardize the life of the patient. methods: We developed a study including seven national institutions affiliated with the Seguro Popular insurance program. We conducted a summary of the clinical records of the most recent death of a pediatric patient with ALL at each institution. Clinical files were analyzed by an expert panel. Results were described and prioritized in order to recommend improvements for care. Results: We considered that 4/7 deaths were preventable. Problems in patient care are related to mismanagement of infectious and hematological complications. Many of the results obtained in the analysis are shared by the institutions with particular emphasis on lack of personnel and insufficient training as well as deficiency of blood products. Conclusions: This study will become the starting point to acknowledge the deficiencies among the different institutions and invites an analysis of the information to create committees for better care practices and to consider RCA as a useful tool within each medical institution to identify deficiencies in the care process.
- Subjects
LYMPHOBLASTIC leukemia in children; MEDICAL care; HEALTH insurance; CHILD mortality; BLOOD diseases; MEDICAL records; PEDIATRICS; LEUKEMIA treatment
- Publication
Boletín Médico del Hospital Infantil de México, 2012, Vol 69, Issue 3, p255
- ISSN
0539-6115
- Publication type
Article