Tracking medication pathway as per better securing drugs' use in three clinical departments at the University hospital of Monastir (Tunisia).

BACKGROUND: In Tunisia, few studies have an interest to the assessment of medication errors and the implementation of preventive measures. The aim of this study was to evaluate the barriers existing in hospital pharmacies in order to prevent medication errors and to help institutions to make improvement actions. methods: First step: a clinical audit was conducted by observation against a set of standards that are representing a guideline. Second step: interview with health professionals to identify their perceptions about medication safety. Third step: in this step we develop adverse events scenarios according to results of the clinical audit in order to be investigated by the field practice. Fourth step: organizing a multi-professional feedback meeting to raise health professional's awareness and to make them more conscientious about adverse drug events negative consequences and invite them to contribute in the establishment and implementation of corrective solutions. results: In the participating departments medical prescription did not include patient information's (age, weight medical background). Nurses do not verify systematically duration of prescription and administration route. Health professionals interview revealed that physician's have lack of awareness about prescription rules. Lack of communication was the main nurse's problem that requires improvement. CONCLUSION: This project has led to a first overview of the situation of medication use in Tunisia. Results will be used to create a dynamic process to improve the medication system safety.

Patient safety in developing countries: retrospective estimation of scale and nature of harm to patients in hospital.

OBJECTIVE: To assess the frequency and nature of adverse events to patients in selected hospitals in developing or transitional economies. DESIGN: Retrospective medical record review of hospital admissions during 2005 in eight countries. SETTING: Ministries of Health of Egypt, Jordan, Kenya, Morocco, Tunisia, Sudan, South Africa and Yemen; the World Health Organisation (WHO) Eastern Mediterranean and African Regions (EMRO and AFRO), and WHO Patient Safety. PARTICIPANTS: Convenience sample of 26 hospitals from which 15,548 patient records were randomly sampled. MAIN OUTCOME MEASURES: Two stage screening. Initial screening based on 18 explicit criteria. Records that screened positive were then reviewed by a senior physician for determination of adverse event, its preventability, and the resulting disability. RESULTS: Of the 15,548 records reviewed, 8.2% showed at least one adverse event, with a range of 2.5% to 18.4% per country. Of these events, 83% were judged to be preventable, while about 30% were associated with death of the patient. About 34% adverse events were from therapeutic errors in relatively non-complex clinical situations. Inadequate training and supervision of clinical staff or the failure to follow policies or protocols contributed to most events. CONCLUSIONS: Unsafe patient care represents a serious and considerable danger to patients in the hospitals that were studied, and hence should be a high priority public health problem. Many other developing and transitional economies will probably share similar rates of harm and similar contributory factors. The convenience sampling of hospitals might limit the interpretation of results, but the identified adverse event rates show an estimate that should stimulate and facilitate the urgent institution of appropriate remedial action and also to trigger more research. Prevention of these adverse events will be complex and involves improving basic clinical processes and does not simply depend on the provision of more resources.

Patient Safety Friendly Hospital Initiative: from evidence to action in seven developing country hospitals.

QUALITY PROBLEM: Recent evidence in the level of patient safety from hospitals in six developing countries in the Eastern Mediterranean Region has demonstrated the high prevalence of adverse events, the excessive rate of death and permanent disability and their high preventability. The Patient Safety Friendly Hospital Initiative (PSFHI) has been launched to respond to these challenges. INITIAL ASSESSMENT: The principal approach of the PSFHI has been to develop an assessment manual that has 140 patient safety standards across five domains--leadership and management, patients and public involvement, safe evidence-based clinical practices, safe environment and lifelong learning. CHOICE OF SOLUTION AND IMPLEMENTATION: Ministries of health of seven countries--Egypt, Jordan, Morocco, Pakistan, Sudan, Tunisia and Yemen were asked to nominate one hospital for assessment and then follow-up with an improvement plan. EVALUATION: The standards are divided into critical (20), core (90) and developmental (30). The range of critical standards, the compulsory standards with which a hospital has to comply, achieved by participating hospitals was 8-78%. Overall, in the domain of leadership and management the highest compliance was 47%, for patients and public involvement 25%, for safe evidence-based clinical practice 53%, for safe environment 64% and for lifelong learning 27%. LESSONS LEARNED: This is the first systematic multi-country initiative in the Eastern Mediterranean Region, which provides compelling evidence that assessment of patient safety standards is feasible and applicable in resource-poor settings and there are significant opportunities for improving the level of patient safety in these hospitals.

[Epidemiological and chronological profile of the low birth weight in the region of Monastir (Tunisia) between 1994 and 2007]. / Caractéristiques épidémiologiques et chronologiques du faible poids de naissance dans la région de monastir (Tunisie) entre 1994 et 2007.

In Tunisia, despite the activities of national programs of maternal and child health, low birth weight (LBW) remains common. The aim of this study is to draw up the epidemiological profile of the LBW in the region of Monastir and to study the chronological trends of the associated factors during a period of 14 years (1994-2007). We conducted a population study which interest 97.630 live births (from 26 to 43 weeks) in the public maternities of the region of Monastir. The mean's age of pregnant women was 28.7 +/- 5.5 years. Among them 14.2% were aged 35 and older and 40% were primipara. Newborns were in term in 94.7% of cases. Maternal age, prenatal care, twin pregnancies and fetal complications were the factors independently associated with the occurrence of LBW in term newborns. However, only prenatal care and twin pregnancies were independently associated to LBW in preterm newborns. During the fourteenth years of the study the parturient mean age and the frequency of preterm birth increased significantly (P < 0.001) while the frequency of multiparty decreased significantly (P < 0.001). We found that the risk factors of LBW (advanced age, multiparty, etc.) are still common in our country and require targeted interventions.

Epidemiological profile of health-care-associated infections in the central-east area of Tunisia.

This study aimed to estimate the prevalence and risk factors for health-care-associated infection (HAl) in all 9 hospitals of the central-east area of Tunisia in 2005. Of 1373 patients admitted for more than 48 hours, 74 developed HAI, a prevalence of 5.4% (95% CI: 4.2%-6.6%). The prevalence was significantly higher in the intensive care units (18.4%) and neonatal departments (12.7%). There were 79 infections and the most frequent sites of infection were respiratory tract and urinary tract. Microbiological examination was performed for 25 cases of HAl and Pseudomonas aeruginosa was identified in 8 cases. Multiple logistic regression analysis indicated that HAl was linked to diabetes (OR = 2.0), immunosuppression (OR = 3.3), length of stay (OR = 4.5), central venous catheter (OR = 2.5) and peripheral venous catheter (OR= 10.2). We conclude that HAls are of concern in this area of Tunisia.

Epidemiological profile of health-care-associated infections in the central-east area of Tunisia

This study aimed to estimate the prevalence and risk factors for health-care-associated infection [HAI] in all 9 hospitals of the central-east area of Tunisia in 2005. Of 1373 patients admitted for more than 48 hours, 74 developed HAI, a prevalence of 5.4% [95% Cl: 4.2%-6.6%]. The prevalence was significantly higher in the intensive care units [18.4%] and neonatal departments [12.7%]. There were 79 infections and the most frequent sites of infection were respiratory tract and urinary tract. Microbiological examination was performed for 25 cases of HAI and Pseudomonas aeruginosa was identified in 8 cases. Multiple logistic regression analysis indicated that HAI was linked to diabetes [OR = 2.0], immunosuppression [OR = 3.3], length of stay [OR = 4.5], central venous catheter [OR = 2.5] and peripheral venous catheter [OR = 10.2]. We conclude that HAI sare of concern in this area of Tunisia

[New criteria and quality of health care services in the governorate of Monastir, Tunisia]. / Les nouveaux critères et la qualité des services de soins de santé dans le gouvernorat de Monastir (Tunisie).

In 2005 new quality criteria (7 items) were introduced for services provided to mother and child under the national perinatality programme. We evaluated this new version in a descriptive study conducted among a random sample of 400 parturient women from Monastir governorate. Mean age was 29.3 (SD 5) years and 42% were primipara. Although prenatal care was adequate in terms of number of antenatal visits for 82.5% of women, for only 21% were all 7 quality criteria fulfilled. The rates of caesarean section and premature birth were significantly higher in women who received quality care (P < 0.05). In logistic regression analysis, age and parity were the only factors independently associated with the quality of care. Additional efforts are needed to ensure good maternal and infant quality of care.

[New criteria and quality of health care services in the governorate of Monastir, Tunisia]

In 2005 new quality criteria [7 items] were introduced for services provided to mother and child under the national perinatality programme. We evaluated this new version in a descriptive study conducted among a random sample of 400 parturient women from Monastir governorate. Mean age was 29.3 [SD 5] years and 42% were primipara. Although prenatal care was adequate in terms of number of antenatal visits for 82.5% of women, for only 21% were all 7 quality criteria fulfilled. The rates of caesarean section and premature birth were significantly higher in women who received quality care [P < 0.05]. In logistic regression analysis, age and parity were the only factors independently associated with the quality of care. Additional efforts are needed to ensure good maternal and infant quality of care

Implementing a quality improvement programme in a family planning centre in Monastir, Tunisia.

We aimed to improve the quality of family planning and reproductive health services in a family planning centre though implementation of a quality improvement programme. Clients were surveyed to identify quality-related problems. Health care teams then analysed the causes of the problems, developed solutions for 3 selected ones and established a quality assurance framework. The selected issues were: long waiting time at the centre; insufficient integration of family planning and reproductive health services; and lack of a holistic approach. The final phase was aimed at testing and implementing corrective measures.

Implementing a quality improvement programme in a family planning centre in Monastir, Tunisia

We aimed to improve the quality of family planning and reproductive health services in a family planning centre though implementation of a quality improvement programme. Clients were surveyed to identify quality-related problems. Health care teams then analysed the causes of the problems, developed solutions for 3 selected ones and established a quality assurance framework. The selected issues were: long waiting time at the centre; insufficient integration of family planning and reproductive health services; and lack of a holistic approach. The final phase was aimed at testing and implementing corrective measures

[Maternal nutrition as a determinant of fetal weight: role of trace elements and vitamins]. / Alimentation maternelle et poids foetal: rôle des oligoéléments et vitamines.

OBJECTIVE: To evaluate maternal trace elements and vitamins food intake in the last month of pregnancy and assess their effect on fetal weight. MATERIAL AND METHODS: It is a food intake survey led near 350 pregnant women. All women participated in a nutritional survey and were at term. To examine dietary intakes, food frequency questionnaires were completed before delivery on the diet during the last 24 hours. Authors compared the maternal intakes to the recommended allowance and analyzed the correlation between these intakes and fetal weight. RESULTS: This study confirmed the influence of factors such as parity, maternal BMI and term of pregnancy on the fetal weight. The mean daily intakes of iron (10.7 mg/day), calcium (553 mg/day), zinc (6.2 mg/day), magnesium (284.3 mg/day) were lower than recommended. The mean daily intakes of vitamins C and E did not differ from recommended allowance. Only calcium intakes were significantly correlated to birth weight. CONCLUSION: We noted a deficiency of most of these intakes compared to the recommended dietary allowance. Trace elements and vitamins C, E maternal-food intakes in the end of pregnancy don't seem to be a significant determinant of foetal weight.

[Distribution of anthropometrical parameters in infants in the Monastir region, Tunisia]. / Distribution des paramètres anthropométriques des nourrissons dans la région de Monastir (Tunisie).

We evaluated the distribution of anthropometrical parameters in infants in Monastir and compared them with the National Center of Health Statistics reference. Our prospective study included 3033 infants attending primary health care centres for vaccinations who were followed for 18 months. In each visit, we measured weight-for-age, height-for-age and weight-for-height. We found a difference between our distribution curve and the NCHS reference. The prevalence of growth retardation increased with age. The prevalence of under-weight and of wasting were less than 10%. Obesity was seen 6.2% of infants aged 3 months and 11.6% aged 9 months.

[Anthropometrical parameters in infants in Monastir region, Tunisia]

We evaluated the distribution of anthropometrical parameters in infants in Monastir and compared them with the National Center of Health Statistics reference. Our prospective study included 3033 infants attending primary health care centres for vaccinations who were followed for 18 months. In each visit, we measured weight-for-age, height-for-age and weight-for-height. We found a difference between our distribution curve and the NCHS reference. The prevalence of growth retardation increased with age. The prevalence of under-weight and of wasting were less than 10%. Obesity was seen 6.2% of infants aged 3 months and 11.6% aged 9 months

[Paramedical staff knowledge and practice related to the blood transfusion safety]. / Connaissances et pratiques du personnel soignant en matière de sécurité transfusionnelle.

Blood transfusion is a complex activity, involving many actors. It is a high risk activity which couldn't be controlled without the use of specific methods. Health care workers beliefs and organisational factors are two major issues for the blood transfusion safety. Our study objectives were to describe the paramedical staff's knowledge and practice regarding blood transfusion safety and to identify factors that are related to them. We carried out a cross sectional study. The information was gathered by using a questionnaire. The latter was developed by foreign teams and adapted to the local context. Two outcome measures were used: the knowledge and practice score and the proportion of true answers. The study showed that only 15% of the interviewed persons have had a score less than 30 (scale range from 0 to 100), i.e. only 15% have had appropriate knowledge and practice with no negative consequences for the patient safety. 13.8% of the study population provided right answers related to the biologic exams required before red cells transfusion and 34% for the abnormal reaction circumstances. These results underscores the importance of strategies improving the quality and the safety of blood transfusion, i.e. the continuous medical education, implementing a blood transfusion information system and the use of transfusion practice guidelines.

[Analysis of the appropriateness of hospitalizations in Monastir, Tunisia]. / Analyse de la pertinence des hospitalisations dans la région de Monastir (Tunisie).

We aimed to measure the extent of inappropriate hospital admissions and to identify factors associated with inappropriate hospital use. A descriptive study was carried out on a randomized sample of 411 hospitalizations in 3 regional hospitals. The appropriateness of admissions was assessed using the Appropriateness Evaluation Protocol (AEP). We found 21% (95% CI: 17%-25%) of the admissions were avoidable according to the AEP. Inappropriate admissions were associated with the hospital (P = 0.005), patient age (P = 0.003), length of stay and diagnosis (P < 0.001). The most frequent reasons for appropriate admissions were parenteral therapy, an acute or progressive sensory motor circulatory or respiratory condition sufficient to incapacitate the patient and severe electrolyte or blood gas abnormality. Our study highlights the need to improve hospital management and to develop alternatives to hospitalization.

[Analysis of the appropriateness of hospitalizations in Monastir, Tunisia]

We aimed to measure the extent of inappropriate hospital admissions and to identify factors associated with inappropriate hospital use. A descriptive study was carried out on a r and omized sample of 411 hospitalizations in 3 regional hospitals. The appropriateness of admissions was assessed using the Appropriateness Evaluation Protocol [AEP]. We found 21% [95% CI: 17%-25%] of the admissions were avoidable according to the AEP. Inappropriate admissions were associated with the hospital [P = 0.005], patient age [P = 0.003], length of stay and diagnosis [P < 0.001]. The most frequent reasons for appropriate admissions were parenteral therapy, an acute or progressive sensory motor circulatory or respiratory condition sufficient to incapacitate the patient and severe electrolyte or blood gas abnormality. Our study highlights the need to improve hospital management and to develop alternatives to hospitalization

Cervical human papillomavirus infection in Tunisian women.

BACKGROUND: It is well established that certain types of human papillomavirus (HPV) are the sexually transmitted agents etiologically linked to cervical cancer. Sexual habits have been shown to be a major determining factor for HPV infection. A large study was carried out to investigate the prevalence and risk factors associated with cervical infection with HPV in Tunisian women. MATERIALS AND METHODS: PCR and restriction enzyme digestion were used to characterize HPV cervical infection in 106 Tunisian married women and 51 legal prostitutes. Epidemiological data were collected and correlated with HPV molecular genotyping. RESULTS: There was a higher relative frequency of HPV-DNA in prostitutes (39%) than in married women (14%) (p = 0.001). Molecular analyses of HPV types showed the most prevalent type in prostitutes to be HPV-16, a high-risk oncogenic type. In married women, the most prevalent type was HPV-6 which is associated with a low risk for cervical cancer. HPV-DNA detection was markedly increased in young adult women and in those having recent sexual experience. CONCLUSION: Cervical HPV infection in Tunisia is less frequent than in other African countries, but far from uncommon. The decrease of HPV prevalence in older women, regardless of their sexual behavior, may result from an efficient immune response acquired with age.

Balloon dilatation of anastomotic strictures secondary to surgical repair of oesophageal atresia.

The purpose of this study was to evaluate the efficiency and safety of oesophageal balloon dilatation in strictures secondary to surgical treatment of oesophageal atresia in 25 children. Patients comprised 15 males and 10 females, aged 1-36 months. Median age was 4 months (interquartile range (IQR)=19). The strictures were more than 50% of oesophageal lumen and the delay from surgical treatment to balloon dilatation varied from 1 month to 36 months. Associated gastroesophageal reflux was noted in 15 patients. All procedures were performed under sedation using fluoroscopic guidance. Balloons of increasing diameter, 4-20 mm were used. Water soluble contrast swallow was performed after each dilatation session. A total of 115 balloon dilatation sessions were performed with a range of 1-14 procedures per patient (median 4 dilatations, IQR=4.5). Dilatation relieved the stricture in all patients over a follow-up period varying from 4 months to 33 months. The best results were noted in children under 6 months, who needed two or few dilatation sessions, with relative risk (RR) of 0.52 and 95% confidence interval of 0.29-0.92. The presence of associated gastroesophageal reflux indicated a high risk (RR of 12, p<0.001) for undergoing more than two balloon dilatation sessions. The only serious complications observed were two cases of oesophageal perforation, which were treated conservatively. Fluoroscopically guided balloon dilatation is a safe and effective treatment in the management of strictures secondary to surgical repair of oesophageal atresia, especially when started early (within 6 months of surgery) and not associated with gastroesophageal reflux.

[Epidemiology of low birth weight in Tunisia]. / Epidémiologie de l'insuffisance pondérale àla naissance dans le Sahel tunisien.

Our study aims to assess the determinants and the frequency of low birth weight (LBW) in the health district of Monastir (Tunisia). The study was carried out over a three-year period, beginning in January 1995 and ending in December 1997. According to the Monastir district's childbirth register, 1,194 of the 21,393 newborns delivered were babies born with a low birth weight (LBW rate of 5.6%). Common characteristics among the LBW infants were the following: females are more often affected than males (sex ratio of 1.25); 22% of cases were twins; one-third were premature births (< 37 weeks). This study of the determinants of LBW demonstrates that there are several factors linked to the occurrence of LBW such as the mother's age, the number of times she has given birth, an interval between pregnancies of less than 24 months, lack of prenatal care, and the female sex of the baby.