Patient-centeredness-a cultural targeted survey among junior medical managers.

BACKGROUND: Patient-centeredness is a core element in healthcare. However, there is a gap between the understanding of this term by healthcare professionals, and patients' capability, self-efficacy, and willingness to take part in medical decisions. We aim to expose standpoints toward "patient centeredness" among junior medical managers (JMM), as they bridge between policy strategies and patients. We try to reveal cultural differences by comparing the views of the majority and the minority subpopulations of Israel (Arabic and Hebrew speakers). METHODS: A cross-sectional survey among JMM studying for an advanced degree in health-system management at three academic training colleges in Israel was conducted in February-March 2022. The respondents completed a structured questionnaire comprising four sections: a) perceptions of trust, accountability, insurance coverage, and economic status; b) perceptions regarding decision-making mechanisms; c) preferences toward achieving equity, and d) demographic details. RESULTS: A total of 192 respondents were included in the study-50% Hebrew speakers and 50% Arabic speakers. No differences were found between Arabic and Hebrew speakers regarding perception of trust, accountability, insurance coverage, and economic status. JMM from both subpopulations believed that patients' gender and age do not influence physicians' attitudes but Arabic-speaking respondents perceived that healthcare professionals prefer educated patients or those with supportive families. All respondents believed that patients would like to be more involved in medical decisions; yet Arabic-speakers perceived patients as tending to rely on physicians' recommendations while Hebrew speakers believed that patients wish to lead the medical decision by themselves. CONCLUSIONS: Patient-centeredness strategy needs to be implemented bottom-up as well as top-down, in a transparent nationwide manner. JMM are key actors in carrying out this strategy because they realize policy guidelines in the context of social disparities, enabling them to achieve a friendly personalized dialogue with their patients. We believe that empowering these JMM may create a ripple effect, yielding a bottom-up perception of equity and initiating change.

Group versus individual occupational therapy for toddlers with autism as a means to improve access to public health-care services. Randomised controlled pilot study.

INTRODUCTION: In recent years, the increasing prevalence of autism-spectrum disorder has resulted in an increased demand for therapies including occupational therapy. In this pilot trial, we aimed to compare the efficacy of group versus individual occupational therapy among toddlers with autism as a means to improve accessibility to care. METHODS: Toddlers (2-4 years) undergoing autism evaluation in our public child developmental centre were recruited and randomised to receive 12 weekly sessions of group or individual occupational therapy based on the same mode of intervention: Developmental, Individual-Differences and Relationship-based (DIR). Primary outcomes related to intervention implementation included waiting days, nonattendance, intervention period, number of sessions attended and therapist satisfaction. Secondary outcomes were the Adaptive Behaviour Assessment System questionnaire, the Paediatric Quality of Life Inventory and the Peabody Developmental Motor Scale (PDMS-2). RESULTS: Twenty toddlers with autism were included, 10 in each occupational therapy mode of intervention. Children waited fewer days before beginning group occupational therapy compared to individual therapy (52.4 ± 28.1 vs. 108.8 ± 48.0 days p < 0.01). Mean numbers of nonattendance was similar for both interventions (3.2 ± 2.82 vs. 2 ± 1.76, p > 0.05). Worker satisfaction scores were similar at the beginning and end of the study (6.1 ± 0.4 vs. 6.07 ± 0.49, p > 0.05). There were no significant differences between the percentage changes in individual and group therapy outcomes for adaptive score (6.0 ± 16.0 vs. 4.5 ± 17.9, p > 0.05), quality of life (1.3 ± 20.9 vs. 18.8 ± 24.5, p > 0.05) and fine motor skills (13.7 ± 36.1 vs. 15.1 ± 41.5, p > 0.05). CONCLUSIONS: In this pilot study, the group DIR-based occupational therapy for toddlers with autism improved access to services and allowed earlier interventions, with no clinical inferiority to individual therapy. Further research is required to examine group clinical therapy benefit.

Patient preferences and choices as a reflection of trust-A cluster analysis comparing postsurgical perceptions in a private and a public hospital.

BACKGROUND: Active participation of patients in managing their medical treatment is a major component of the patient empowerment process and may contribute to better clinical outcomes. Patient perceptions and preferences affect the patient-physician encounter in a variety of dimensions, such as patient autonomy, freedom of choice and trust in the healthcare system. The Israeli healthcare system is mostly publicly funded, with additional private healthcare services for surgery and other medical treatments. The aim of this study was to compare the perceptions and preferences of patients in the public and private hospitals in Israel. METHODS: A cross-sectional study among 545 individuals who had surgical procedures at two hospitals in Israel (one public and one private). A structured questionnaire comprising 23 items was used to collect perceptions via personal telephone interviews. The responses were categorized into five clusters and compared by type of health services provider (public vs. private) and sociodemographic characteristics (gender, age and education level). RESULTS: A hierarchical cluster analysis methodology identified five conceptual groups: trust, concern towards medical errors, dialogue between medical staff and the patient/patient's family, confidentiality and staff bias towards more informed patients, or those with supportive families. Four main themes that highlight patients' preferences were found: physical conditions, personal empowerment and perceived autonomy, patient experience and patient-provider encounter communication. Significant differences between the private and the public healthcare systems were found in four clusters: trust and patient care, patient's concerns, the extent of explanation and medical staff's commitment. Differences secondary to sociodemographic parameters were noticed: patients treated at the private hospital scored significantly higher items of trust, medical staff caring and the importance of choosing their treating surgeon, while patients treated at the public hospital scored higher staff commitment to the patient than those treated at the private hospital. CONCLUSIONS: The study revealed the perceptions underlying the decisions of patients to undergo surgical procedures in public or private hospitals. Mutual learning could pave the way to better patient-physician encounters. PATIENT OR PUBLIC CONTRIBUTION: Patients from the two hospitals were involved in this study by responding to the questionnaire. The data presented is based on the patient's responses.

[EDUCATING MEDICAL STUDENTS TO PROFESSIONALISM AND SAFETY IN HEALTHCARE AND THE IMPACT OF THE COVID-19 EPIDEMIC - AN ISRAELI PERSPECTIVE].

INTRODUCTION: Medical students' education traditionally focuses on professionalism (knowledge and skills) alongside compassion. Recently, the importance of quality of care, safety and error prevention has increased. Teaching students through adopting the terminology, tools and insights of quality and safety will not only promote safety, but may also increase treatment effectiveness, patient satisfaction and staff commitment. The Covid-19 epidemic, enforcing social distancing and strict protective actions, have all deepened the challenges in safety-targeted education, incurring implementation difficulties: 1) restricting bedside teaching; 2) reducing simulations and clerkship peer discussions;, 3) distorting the equilibrium of risk management/safety insight and clinical perception significance (anamnesis, physical examination). AIMS: This study aimed to examine standpoints towards safety education in medical studies among students and teacher. METHODS: A survey was conducted among students in pre-clinical courses, department directors/tutors and focus-group discussions among managers. RESULTS: Medical students ranked safety-targeted education as highly important alongside academic knowledge, clinical skills and compassion. Department head managers and teaching physicians rated compassion and safety as highly important, more than research curiosity, values, resilience, family involvement and clinical proficiency, and much more than technical skills and the patient's preferences. In the first epidemic wave, safety-targeted education was graded higher by the focus-group leaders, when compared to teaching physicians, and scoring was similar for resilience, compassion, proficiency and knowledge. During the second wave, the department heads emphasized the importance of safety. CONCLUSIONS: Transparency analysis of medical students' standpoints may reveal barriers to implement safety/quality measures in their curriculum.

[THE FUTURE OF HOSPITALS IN ISRAEL - PLANNING CONSIDERATIONS AND THE STANDPOINTS OF MANAGERS].

INTRODUCTION: Planning the future national hospitalization system requires consideration of demographic trends, innovative treatments and policy approaches. The existing situation alone does not allow proper planning in extremely dynamic systems that operate within the framework of scarce resources. OBJECTIVES: To identify managers' attitudes regarding hospital planning, deployment and managerial mechanisms in comparison with evidence in the literature. METHODS: A survey among hospital managers following a focused conference. RESULTS: Of the 50 respondents, half of the group thought that a general hospital should include 900-2000 beds. The majority prefer an autonomous management style, or a cluster of only a few hospitals. In a scenario of overload and shortage of beds, the majority prefer adding beds to the existing hospital, while about a quarter of the respondents suggest establishing another hospital in the area, or merging nearby hospitals. About half supported home care, or transferring patients to a nearby hospital, including in the private sector, or the transfer of appropriate patients to chronic care institutions. About a third of the respondents supported telemedicine. In terms of national deployment, the preference was that the hospital should be located in high population areas and able to provide sufficient geographical accessibility. Yet, 60% of participants emphasized the importance of social determinants to low socio-economic populations. CONCLUSIONS: The survey revealed original standpoints and ideas towards willingness to promote targeted solutions. Healthcare leaders should consider and adapt local ideas to achieve effective planning following the insights of those working in the field. DISCUSSION: Targeted conferences aimed at discussing health policy are an effective platform for presenting complex issues and for sharing ideas with colleagues for the benefit of meaningful long-term processes.

Developing a new flexible tool for handover.

BACKGROUND: Transferring medical information among professionals and between shifts is a crucial process, allowing continuity of care and safety, especially for complex patients in life-threatening situations. This process, handover, requires focusing on specific, essential medical information while filtering out redundant and unnecessary details. OBJECTIVES: To create and implement a tool for handover that would be flexible enough to meet the unique needs of specific departments. METHODS: We used Plan-Do-Study-Act (PDSA) methodology to prospectively develop, implement, evaluate and reassess a new handover tool in a 900-bed teaching hospital in central Israel. Nurses from 35 departments participated in developing a tool that presents the staff's viewpoint regarding the most critical information needed for handover. RESULTS: A total of 78 nurse managers and 15 doctors (63.7%) completed the questionnaire. Based on exploratory factor analysis, 15 items explained 58.9% of the variance. Four key areas for handover were identified, in addition to basic patient identification: (i) updated clinical status, (ii) medical information, (iii) special clinical treatment and (iv) treatments not yet initiated. Subsequently, a Flexible Handover Structured Tool (FAST) was designed that identifies patients' needs and is flexible for the specific needs of departments. Revisions based on hands-on experience led to high nurse satisfaction with the new tool in most departments. The FAST format was adopted easily during the COVID-19 pandemic. CONCLUSION: Implementing a new handover tool-FAST-was challenging, but rewarding. Using PDSA methodology enabled continuous monitoring, oversight and adaptive corrections for better implementation of this new handover reporting tool.

The bone marrow is patrolled by NK cells that are primed and expand in response to systemic viral activation.

The bone marrow hosts NK cells whose distribution, motility and response to systemic immune challenge are poorly understood. At steady state, two-photon microscopy of the bone marrow in Ncr1gfp/+ mice captured motile NK cells interacting with dendritic cells. NK cells expressed markers and effector molecules of mature cells. Following poly (I:C) injection, RNA-Seq of NK cells revealed three phases of transcription featuring immune response genes followed by posttranscriptional processes and proliferation. Functionally, poly (I:C) promoted upregulation of granzyme B, enhanced cytotoxicity in vitro and in vivo, and, in the same individual cells, triggered proliferation. Two-photon imaging revealed that the proportion of sinusoidal NK cells decreased, while at the same time parenchymal NK cells accelerated, swelled and divided within the bone marrow. MVA viremia induced similar responses. Our findings demonstrate that the bone marrow is patrolled by mature NK cells that rapidly proliferate in response to systemic viral challenge while maintaining their effector functions.

Truth-telling and doctor-assisted death as perceived by Israeli physicians.

BACKGROUND: Medicine has undergone substantial changes in the way medical dilemmas are being dealt with. Here we explore the attitude of Israeli physicians to two debatable dilemmas: disclosing the full truth to patients about a poor medical prognosis, and assisting terminally ill patients in ending their lives. METHODS: Attitudes towards medico-ethical dilemmas were examined through a nationwide online survey conducted among members of the Israeli Medical Association, yielding 2926 responses. RESULTS: Close to 60% of the respondents supported doctor-assisted death, while one third rejected it. Half of the respondents opposed disclosure of the full truth about a poor medical prognosis, and the others supported it. Support for truth-telling was higher among younger physicians, and support for doctor-assisted death was higher among females and among physicians practicing in hospitals. One quarter of respondents supported both truth-telling and assisted death, thereby exhibiting respect for patients' autonomy. This approach characterizes younger doctors and is less frequent among general practitioners. Another quarter of the respondents rejected truth-telling, yet supported assisted death, thereby manifesting compassionate pragmatism. This was associated with medical education, being more frequent among doctors educated in Israel, than those educated abroad. All this suggests that both personal attributes and professional experience affect attitudes of physicians to ethical questions. CONCLUSIONS: Examination of attitudes to two debatable medical dilemmas allowed portrayal of the multi-faceted medico-ethical scene in Israel. Moreover, this study, demonstrates that one can probe the ethical atmosphere of a given medical community, at various time points by using a few carefully selected questions.

Hospital staff perspectives towards health technology assessment: data from a multidisciplinary survey.

BACKGROUND: Technology adoption in hospitals is usually based on cost-effectiveness analysis, feasibility and potential success. Different countries have embraced a range of principles to accomplish an effective comprehensive process of health technology assessment (HTA). The aim of the study was to analyse the viewpoints and relative weight of technology-oriented hospital staff members toward the clinical, social, technological and economic aspects of HTA. METHODS: Using a structured questionnaire, a survey was conducted among different professionals in an 850-bed hospital. RESULTS: We revealed a range of viewpoints among hospital staff members according to their personal characteristics and professional standpoints. The clinical aspects of HTA were considered 'highly important' (HI) by most participants, especially the 'lifesaving' parameter. Similarly, the 'lack of effective alternative technology' was ranked HI by a high percentage of participants, independent of their profession. Economic aspects were ranked HI only by half of the participants, while social and technological aspects were ranked HI only by a relatively low percentage. Nurses added 'improving quality of life', 'increasing teamwork efficiency' and 'improving medical standards'. Allied health professionals focused on 'lack of effective alternative technologies' as a main argument for adoption of HTA, alongside increasing efficiency, budget savings and contribution to hospital reputation. Engineers emphasised the requirement of significant investment in infrastructure and increasing efficiency. Administrators ranked patient experience as HI. Interestingly, the high ranking of social aspects correlated with older responders, while junior staff ranked safety significantly higher. CONCLUSIONS: A multi-perspective multidisciplinary approach would be beneficial for policy-makers at hospitals and even on a national scale in Israel.

Active dissemination of cellular antigens by DCs facilitates CD8+ T-cell priming in lymph nodes.

Antigen (Ag) specific activation of naïve T cells by migrating dendritic cells (DCs) is a highly efficient process, although the chances for their colocalization in lymph nodes (LNs) appear low. Ag presentation may be delegated from Ag-donor DCs to the abundant resident DCs, but the routes of Ag transfer and how it facilitates T-cell activation remain unclear. We visualized CD8+ T cell-DC interactions to study the sites, routes, and cells mediating Ag transfer in mice. In vitro, Ag transfer from isolated ovalbumin (OVA)+ bone marrow (BM) DCs triggered widespread arrest, Ca2+ flux, and CD69 upregulation in OT-I T cells contacting recipient DCs. Intravital two-photon imaging revealed that survival of Ag-donor DCs in LNs was required for Ag dissemination among resident CD11c+ DCs. Upon interaction with recipient DCs, CD8+ T cells clustered, upregulated CD69, proliferated and differentiated into effectors. Few DCs sufficed for activation, and for efficient Ag dissemination lymphocyte function associated antigen 1 (LFA-1) expression on recipient DCs was essential. Similar findings characterized DCs infected with a replication-deficient OVA-expressing Vaccinia virus known to downregulate MHC-I. Overall, active Ag dissemination from live incoming DCs helped activate CD8+ T cells by increasing the number of effective presenting cells and salvaged T-cell priming when Ag-donor DCs could not present Ag.

Adverse Drug Event Rate in Israeli Hospitals: Validation of an International Trigger Tool and an International Comparison Study.

BACKGROUND: Adverse drug events (ADEs) are a major cause of morbidity and mortality worldwide. Hence, identifying and monitoring ADEs is of utmost importance. The Trigger Tool introduced by the Institute of Healthcare Improvement in the United States has been used in various countries worldwide, but has yet to be validated in Israel. OBJECTIVES: To validate the international Trigger Tool in Israel and to compare the results with those generated in various countries. METHODS: A retrospective descriptive correlative analysis surveying four general hospitals in Israel from different geographical regions was conducted. Patient medical charts (n=960) were screened for 17 established triggers and confirmed for the presence of an ADE. Trigger incidence was compared to the actual ADE rate. Further comparison among countries was conducted using published literature describing Trigger Tool validation in various countries. RESULTS: A total of 421 triggers in 279 hospitalizations were identified, of which 75 ADEs in 72 hospitalizations (7.5%) were confirmed. In addition, two ADEs were identified by chart review only. Mean positive predictive value was 17.81% and overall sensitivity was 97%. We found 1.54 ADEs for every 100 hospitalization days, 7.8 ADEs per 100 admissions, and 1.81 ADEs for every 1000 doses of medication. Of the 77 ADEs identified, 22.7% were defined as preventable. CONCLUSIONS: Our results support the Trigger Tool validity in Israel as a standardized method. Further studies should evaluate between hospital and region differences in ADE rate, in particular for the preventable events.

[HOSPITAL ACCREDITATION - TIME FOR RETHINKING?]

INTRODUCTION: Accreditation provides an incentive to promote processes improving quality and enhancing patient safety, both in hospital and community settings. For the past three decades, many western, as well as developing countries, have adopted this methodology. Israel too has taken this pathway to adopt accreditation in general, geriatric and psychiatric hospitals as part of a national mission. Beyond the benefits to the patient, accreditation has numerous advantages: raising the professional accountability of healthcare providers, defining targets for improvement based on the strategies of the Ministry of Health and specifying standardization of care and regulations. Accreditation guides care-givers to develop insights on the quality and perception of innovation and facilitates trust, workers' coherence and teamwork. Alongside these benefits, thoughts about the future of the process arise: A variety of accreditation programs exists around the world, while several governments implement other incentives for healthcare system improvement- such as quality indices. Moreover, professionals resist this methodology, which may be considered to be over-complex to maintain. Since we have already assimilated concepts, perspectives, knowledge and experience in this challenging process, the outlook for preserving a nationwide hospital-based accreditation in the current format should be re-examined, in order to establish a long-lasting quality mechanism.

[THE IMPACT OF ACCREDITATION - ACHIEVEMENTS, BENEFITS AND BARRIERS: COMPARING THE VIEWPOINTS OF THE PROCESS LEADERS AND THE HOSPITAL STAFF].

AIMS: Evaluating the impact of the accreditation process on the basis of achievements, benefits and barriers from the viewpoint of leaders of the hospital accreditation in comparison to the hospital staff members. BACKGROUND: The implementation of standards for accreditation aim to improve the safety and quality of treatment. Partaking in this process has raised dilemmas regarding the actual benefits of accreditation in relation to the efforts invested in its achievement. Examining the standpoints of leaders of the process can reflect on the influence of this mechanism both on hospital activity and on hospital staff. METHODS: A survey was conducted among two groups: The first group, the JCI accreditation leaders group, included 35 participants (the steering committee, 15 chapter heads and the hospital management); and 71 participants from the extended headquarters (senior physicians, nurses and administration staff). The second group included 564 hospital personnel from the medical, nursing, alternative medicine, administrators and housekeeping staff. The questionnaire included 46 statements in five fields: the effectiveness and benefit from the process, weaknesses, barriers, leadership and administration of the accreditation. RESULTS: All the respondents to the survey perceived the process as a leverage for implementing significant changes in all levels of the organization. There were high levels of agreement on the benefit of the process regarding the effective and affective contribution - high morale, feelings of accomplishment and team pride, improvement in communication, cooperation and social cohesion. The weaknesses of the process, including financial costs, bureaucracy, paper overflow and work overload, were awarded relatively low scores. The advantages of the process were ranked high in both groups; the accreditation leaders group attributed the process benefits to the organization as a whole, ranking it significantly higher, as well as for the individual. The hospital staff rated as significantly higher: the contribution of the process on the department level and the opportunity to promote accomplishments that were not reached in the past. CONCLUSIONS: The survey raised organizational discussion which minimized the objections to the process of change. Focusing on chosen aspects bridged between managers and on-site staff to find effective solutions. DISCUSSION: In order to promote successful inter-organizational processes the hospital requires both leadership and a well-formulated strategic program. The secondary gains from the broad process encompassing the whole organization, such as in the case of accreditation, are expressed in the form of social cohesion, cooperation, group pride and high staff morale.

['FLEXIBLE WALLS' IN HOSPITALS - ASSESSING THE 'VALUE' OF SOCIAL IMPACT ON ARCHITECTURE].

BACKGROUND: : The development of hospital architecture is influenced by social trends, with mutual influence. Architecture enables 'organic-design' that leads to development, growth and adaptation of the structure to changing functions. A literature review reveals different perceptions of the flexibility of adapting hospital structure to changing needs, focusing on external forces pressures (expensive technologies, budgetary constraints limiting innovation implementation and regulatory barriers), as well as patients' demands. The degree of contribution of structural changes to the measured or perceived benefit to the patient and staff, has not yet been fully assessed. Expressions of this benefit are infection-control and increasing operational efficiency by energy saving and sustainability. OBJECTIVES: To examine workers' perceptions towards value-based-architecture in relation to the patient or staff in a hospital setting. METHODS: A survey was conducted among health care workers who underwent management training, using a structured questionnaire. RESULTS: Sixty responders ranked hospital leadership and relevant professionals (engineers and architects) as key players in the decision to change architecture in a hospital; economists, doctors and nurses were ranked as less important, while patients and families were ranked the lowest. Among the factors that contribute to the 'value' of the decision were the agility to adapt to emergency, and to changing morbidity trends in an efficient way. Factors ranked as being of medium importance were the contribution to hospital profitability and, to a lesser extent, the contribution to branding and improved service. CONCLUSIONS: 'Flexible walls' (shifting rooms between departments according to clinical need) can provide a response to morbidity changes. DISCUSSION: Hospital workers can play a role in the process of value-based architecture, thereby improving decisions concerning hospital construction and increasing their commitment to additional quality processes.

[A MODEL TO SOLVE BARRIERS IN TREATING COMPLEX MEDICAL PATIENTS - 'DIABETIC FOOT' AS A CASE STUDY].

AIMS: To identify barriers for diabetic foot detection within the medical team, to plan and conduct interventions to solve these barriers and to follow-up their outcomes, resulting in creating a model to cope with barriers in the treatment of complicated patients. BACKGROUND: Diabetes mellitus is a rising epidemic worldwide, with a significant medical and economic impact (about 20% of the annual health expenditure). A major complication of diabetes is 'diabetic foot', including neuropathy and peripheral vascular disease, resulting in leg ulcers and amputation. Morbidity and mortality in amputated patients are significantly higher, while in 85% of the patients, a preventable leg ulcer could be detected prior to amputation. Screening and patient education may reduce leg ulcers and amputation by 45%. METHODS: Identify barriers and solutions, ranking their relative weight and correlation matrix, by a focus group. RESULTS: Identifying the relative weight of the barriers, revealed that professional barriers were dominant, followed by policy, administrative and educational barriers. CONCLUSIONS: Identifying barriers and their solutions in the measuring process of quality medical indices, may improve the scope and quality of the measurement, as well as affect health outcomes. A model for detecting barriers increased the involvement of staff to improve processes and promote interdisciplinary communication. It is recommended to intensify the engagement in resolving barriers as part of the quality improvement processes. DISCUSSION: Identifying barriers is a crucial step for their removal. Adjusting optimized solutions, setting a clear policy, guidance and the cooperation of a multidisciplinary team, defining "diabetic foot assessment tool" as a required "quality index", and conducting periodic controls of the implementation of this standard, enhance the translation of policy to feasible activity measures.

[A PUBLIC HOSPITAL IN THE ERA OF 'INNOVATION-DRIVEN MEDICINE' - HUMAN EXCELLENCE AND EVOLVING TECHNOLOGY].

INTRODUCTION: Assaf Harofeh Medical Center is the fourth largest governmental hospital in Israel, with 900 beds, approximately 165,000 annual ER visits, and 23,000 operations. The Medical Center encourages human excellence and medical innovation, together with "patient centered" perspectives, providing optimal holistic service, alongside caring for the staff. The management concept of "participatory leadership" leads to multi-sectorial integration, conducting combined physician-nurse quality projects in all departments. As part of leading the field of quality and accreditation and the desire to share knowledge and experience, the School for Quality and Accreditation was established to train medical teams from the hospital and other medical centers. This issue presents articles that illuminate some of the work on our flourishing campus. The hospital serves a diverse population both demographically, and socio-economically. We feel responsibility for this population beyond the provision of medical care. The many centers of excellence in prominent clinical fields and the platform for providing continuous education for the medical staff to carry out basic and clinical research, are at the forefront for the future. Following demographic expansion of the population around the hospital, the task of providing optimal and equitable medical services is challenging. Over the next decade, the hospital is expected to be united with psychiatric and geriatric hospitals to create an integrated medical center.

The proportion of errors in medical prescriptions and their executions among hospitalized children before and during accreditation.

OBJECTIVE: To evaluate the rate of medication related errors in the pediatric ward and pediatric emergency department (PED), before and after implementing intervention strategies according to the Joint Commission International (JCI) accreditation program. DESIGN: A retrospective cross-sectional study that included chart review. SETTING: A university affiliated pediatric ward and PED. PARTICIPANTS: Children 0-18 years old admitted on February 2013 (before the JCI program) and February 2014 (during implementation of the JCI program). INTERVENTION(S): A training program designed to meet the JCI official standards on medication prescribing. MAIN OUTCOME MEASURE(S): The number of prescribing and medication administration errors in the 2 years. RESULTS: We collected 937 valid prescription orders and 924 administration orders (1861 medical orders) from February 2013, and 961 valid prescription orders and 958 administration orders (1919 medical orders) from February 2014. There was a significant reduction in prescribing errors from 6.5 to 4.2% between years 2013 and 2014 (P = 0.03). There was no significant difference in administration error rates between the two periods (104 (11.3%) in the first period and 114 (11.9%) in the second; P = 0.61). CONCLUSIONS: The errors rate we found was within the range described in the literature. Quality assurance interventions can significantly reduce medication prescribing errors.

[THE SECOND VICTIM: TREATING THE HEALTH CARE PROVIDERS].

INTRODUCTION: During their professional careers, physicians and other health care providers are repeatedly exposed to emotional stress. This is usually secondary to coping with the results of a medical error or complicated medical event. Generally, in the above cases, the patient and his/her family are in the center of the medical system, being "the first victim" of such an event, while the involved caregiver, who provided the medical service, is categorized as the "second victim". "Second victims" may feel anxiety, fear, guilt or anger and experience social withdrawal, which may lead to troubling memories, depression and insomnia. Over the years, this situation may lead to deterioration in his/her work and personal life and, in rare circumstances, may lead to pharmaceutical and even alcohol consumption. In the literature there are even some rare case reports of "second victims" who have committed suicide. To meet these challenges, several leading institutions in western countries have developed formal support programmes that allow health care providers to cope with their emotional distress by obtaining timely support in an emphatic, confidential, non-judgmental environment. The above scheme of support is not meant to disrupt any correct medical investigation or to stand between the "second victim" and his superiors, but rather to allow them to cope with these events. We believe that the time has come to develop national support programs appropriate to our culture and behavioural circumstances. Local health care organizations should build a supporting scheme for the "second victims", helping them to cope with these events, thereby assisting them to return to their daily work and former routine.