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1.
Dermatol Online J ; 27(3)2021 Mar 15.
Artículo en Inglés | MEDLINE | ID: mdl-33865273

RESUMEN

OBJECTIVE: We update and expand our 2010 article in this journal, Patient safety in dermatology: A review of the literature [4][DH1]. METHODS: PubMed at the National Center for Biotechnology Information (NCBI), United States National Library of Medicine (NLM) was searched September 2019 for English language articles published between 2009 and 2019 concerning patient safety and medical error in dermatology. Potentially relevant articles and communications were critically evaluated by the authors with selected references from 2020 added to include specific topics: medication errors, diagnostic errors including telemedicine, office-based surgery, wrong-site procedures, infections including COVID-19, falls, laser safety, scope of practice, and electronic health records. SUMMARY: Hospitals and clinics are adopting the methods of high-reliability organizations to identify and change ineffective practice patterns. Although systems issues are emphasized in patient safety, people are critically important to effective teamwork and leadership. Advancements in procedural and cosmetic dermatology, organizational and clinical guidelines, and the revolution in information technology and electronic health records have introduced new sources of potential error. CONCLUSION: Despite the growing number of dermatologic patient safety studies, our review supports a continuing need for further studies and reports to reduce the number of preventable errors and provide optimal care.


Asunto(s)
Dermatología/estadística & datos numéricos , Seguridad del Paciente , Accidentes por Caídas/prevención & control , Accidentes por Caídas/estadística & datos numéricos , /transmisión , Infección Hospitalaria/prevención & control , Fármacos Dermatológicos/efectos adversos , Errores Diagnósticos/prevención & control , Errores Diagnósticos/estadística & datos numéricos , Documentación , Registros Electrónicos de Salud , Fuego , Humanos , Control de Infecciones , Rayos Láser/efectos adversos , Errores Médicos/prevención & control , Errores Médicos/estadística & datos numéricos , Errores de Medicación/prevención & control , Errores de Medicación/estadística & datos numéricos , Equipo de Protección Personal , Factores de Riesgo
2.
Medicine (Baltimore) ; 100(9): e24956, 2021 Mar 05.
Artículo en Inglés | MEDLINE | ID: mdl-33655962

RESUMEN

INTRODUCTION: Due to the diversity of reports and on the rates of medications errors (MEs) in Saudi Arabia, we performed the first meta-analysis to determine the rate of medications errors in Saudi Arabia using meta-analysis in the hospital settings. METHODS: We conducted a systematic literature search through August 2019 using PubMed, EMBASE, CINAHL, PsycINFO, and Google Scholar to identify all observational studies conducted in hospital settings in Saudi Arabia that reported the rate of MEs. A random-effects models were used to calculate overall MEs, as well as prescribing, dispensing, and administration error rates. The I2 statistics were used to analyze heterogeneity. RESULTS: Sixteen articles were included in this search. The total incidence of MEs in Saudi Arabia hospitals was estimated at 44.4%. Prescribing errors, dispensing errors, and adminstration errors incidents represent 40.2%, 28.2%, and 34.5% out of the total number of reported MEs, respectively. However, between-study heterogeneity was also generally found to be >90% (I-squared statistic). CONCLUSIONS: This study demonstrates the MEs common in health facilities. Additional efforts in the field are needed to improve medication management systems in order to prevent patient harm incidents.


Asunto(s)
Hospitales/estadística & datos numéricos , Errores de Medicación/estadística & datos numéricos , Humanos , Incidencia , Arabia Saudita/epidemiología
3.
Value Health ; 24(2): 147-157, 2021 02.
Artículo en Inglés | MEDLINE | ID: mdl-33518021

RESUMEN

OBJECTIVES: Opioid-related medication errors (MEs) can have a significant impact on patient health and contribute to opioid misuse. The objective of this study was to estimate the incidence of and variables associated with the receipt of an opioid prescription and opioid-related MEs (omissions, duplications, or dose changes) at hospital discharge. We also determined rates of adverse drug events and risks of emergency department visits, readmissions, or death 30 days and 90 days post discharge associated with MEs. METHODS: A cohort of hospitalized patients discharged from the McGill University Health Centre between 2014 and 2016 was assembled. The impact of opioid-related MEs was assessed in a propensity score-adjusted logistic regression models. Multivariable logistic regression was used to determine characteristics associated with MEs and discharge opioid prescription. RESULTS: A total of 1530 (43.9%) of 3486 patients were prescribed opioids, of which 13.4% (n = 205) of patients had at least 1 opioid-related ME. Rates of MEs were higher in handwritten prescriptions compared to the electronic reconciliation discharge prescription group (20.6% vs 1.2%). Computer-based prescriptions were associated with a 69% lower risk of opioid-related MEs (adjusted odds ratio: 0.31, 95% confidence interval: 0.14-0.65) as well as 63% lower risk of receiving an opioid prescription. Opioid-related MEs were associated with a 2.3 times increased risk of healthcare utilization in the 30 days postdischarge period (adjusted odds ratio: 2.32, 95% confidence interval: 1.24-4.32). CONCLUSIONS: Opioid-related MEs are common in handwritten discharge prescriptions. Our findings highlight the need for computer-based prescribing platforms and careful review of medications during critical periods of care such as hospital transitions.


Asunto(s)
Analgésicos Opioides/uso terapéutico , Prescripción Electrónica/normas , Errores de Medicación/estadística & datos numéricos , Alta del Paciente/estadística & datos numéricos , Anciano , Anciano de 80 o más Años , Analgésicos Opioides/administración & dosificación , Analgésicos Opioides/efectos adversos , Continuidad de la Atención al Paciente , Servicio de Urgencia en Hospital/estadística & datos numéricos , Femenino , Humanos , Masculino , Conciliación de Medicamentos/normas , Persona de Mediana Edad , Readmisión del Paciente/estadística & datos numéricos , Pautas de la Práctica en Medicina/estadística & datos numéricos , Estudios Prospectivos
4.
Aten. prim. (Barc., Ed. impr.) ; 53(1): 43-50, ene. 2021. tab, graf
Artículo en Inglés | IBECS | ID: ibc-200088

RESUMEN

OBJECTIVE: To estimate the effectiveness of a Medication Discrepancy Detection Service (MDDS), a collaborative service between the community pharmacy and Primary Care. DESIGN: Non-controlled before-and-after study. SETTING: Bidasoa Integrated Healthcare Organisation, Gipuzkoa, Spain. PARTICIPANTS: The service was provided by a multidisciplinary group of community pharmacists (CPs), general practitioners (GPs), and primary care pharmacists, to patients with discrepancies between their active medical charts and medicines that they were actually taking. Outcomes: The primary outcomes were the number of medicines, the type of discrepancy, and GPs' decisions. Secondary outcomes were time spent by CPs, emergency department (ED) visits, hospital admissions, and costs. RESULTS: The MDDS was provided to 143 patients, and GPs resolved discrepancies for 126 patients. CPs identified 259 discrepancies, among which the main one was patients not taking medicines listed on their active medical charts (66.7%, n = 152). The main GPs' decision was to withdraw the treatment (54.8%, n = 125), which meant that the number of medicines per patient was reduced by 0.92 (9.12 ± 3.82 vs. 8.20 ± 3.81; p < .0001). The number of ED visits and hospital admissions per patient were reduced by 0.10 (0.61 ± .13 vs 0.52 ± 0.91; p = .405 and 0.17 (0.33 ± 0.66 vs. 0.16 ± 0.42; p = .007), respectively. The cost per patient was reduced by (Euro)444.9 ((Euro)1003.3 ± 2165.3 vs. (Euro)558.4 ± 1273.0; p = .018). CONCLUSION: The MDDS resulted in a reduction in the number of medicines per patients and number of hospital admissions, and the service was associated with affordable, cost-effective ratios


OBJETIVOS: Estimar la efectividad del servicio de detección de discrepancias de la medicación, un servicio de colaboración entre la farmacia comunitaria y la atención primaria. DISEÑO: Estudio de intervención antes-después, sin grupo control. Emplazamiento: Organización Sanitaria Integrada de Bidasoa, Gipuzkoa, España. PARTICIPANTES: El servicio fue ofrecido por un grupo multidisciplinar que incluía farmacéuticos comunitarios (FC), médicos de atención primaria (MAP) y farmacéuticos de atención primaria a pacientes que presentaban discrepancias entre la medicación prescrita en la hoja de tratamiento activo y lo que realmente estaban tomando. Mediciones principales: Las variables principales del estudio fueron el número de medicamentos, tipo de discrepancia y la decisión del MAP. Las variables secundarias fueron tiempo invertido por el farmacéutico, visitas al servicio de urgencias, ingresos hospitalarios y los costes. RESULTADOS: El servicio se ofreció a 143 pacientes, y el MAP resolvió las discrepancias de un total de 126 pacientes. El FC identificó 259 discrepancias de las cuales la mayoría fue que el paciente no estaba tomando un medicamento prescrito (66,7%, n = 152). En la mayoría de los casos, la decisión del MAP fue suspender el tratamiento (54,8%, n = 125); el número de medicamentos que tomaba el paciente se redujo en un 0,92 (9,12 ± 3,82 vs. 8,20 ± 3,81; p < 0,0001). El número de visitas al hospital y los ingresos hospitalarios se redujeron en 0,10 (0,61 ± 0,13 vs. 0,52 ± 0,91; p = 0,405) y 0,17 puntos (0,33 ± 0,66 vs. 0,16 ± 0,42; p = 0,007), respectivamente. El coste por paciente se redujo en 444,9 (Euro) (1.003,3 ± 2.165,3 vs. 558,4 (Euro) ± 1.273,0; p = 0,018). CONCLUSIÓN: El servicio redujo el número de medicamentos que tomaba el paciente e ingresos hospitalarios y esto se relacionó con unos ratios de coste-efectividad positivos


Asunto(s)
Humanos , Masculino , Femenino , Persona de Mediana Edad , Anciano , Anciano de 80 o más Años , Errores de Medicación/estadística & datos numéricos , Servicios Comunitarios de Farmacia/estadística & datos numéricos , Atención Primaria de Salud/estadística & datos numéricos , Ensayos Clínicos Controlados no Aleatorios como Asunto , Médicos Generales/estadística & datos numéricos , Farmacéuticos/estadística & datos numéricos , Errores de Medicación/economía , Servicios Comunitarios de Farmacia/economía , Atención Primaria de Salud/economía , Hospitalización/estadística & datos numéricos , Hospitalización/economía
5.
Am J Cardiol ; 144: 52-59, 2021 04 01.
Artículo en Inglés | MEDLINE | ID: mdl-33385355

RESUMEN

Direct Oral Anticoagulants (DOACs) require dose adjustment based on specific patient characteristics, making them prone to incorrect dosing. The current study aimed to evaluate the prevalence of inappropriate DOAC dosing, its predictors, and corresponding outcomes in a single-center cohort of atrial fibrillation (AF) patients. We reviewed all patients with AF treated at Mayo Clinic with a DOAC (Apixaban, Rivaroxaban, or Dabigatran) between 2010 and 2017. Outcomes examined were ischemic stroke /transient ischemic attack (TIA)/embolism and bleeding. 8,576 patients (mean age 69.5 ± 11.9 years, 35.1 % female, CHA2DS2-VASc 3.0±1.8) received a DOAC (38.6% apixaban, 35.8% rivaroxaban, 25.6% dabigatran). DOAC dosing was inappropriate in 1,273 (14.8%) with 1071 (12.4%) receiving an inappropriately low dose, and 202(2.4%) an inappropriately high dose. Patients prescribed inappropriate doses were older (72.4 ± 11.7 vs 69.0 ± 11.8, p <0.0001), more likely to be female (43.1% vs 33.7%, p <0.0001), had a higher CHA2DS2-VASc score (3.4 ± 1.8 vs 2.9 ± 1.8, p <0.0001) and a greater Charlson co-morbidity index (3.5 ± 3.3 vs 2.9 ± 3.2, p<0.0001). Over 1.2 ±1.6 years (median 0.5 years) follow up; there was no significant difference in the incidence of stroke and/or TIA and/or embolism and bleeding between patients who were inappropriately dosed versus appropriately dosed. In conclusion, DOAC dosing was not in compliance with current recommendations in 15% of AF patients. Patients at higher risk of stroke and/or TIA based on older age, female gender, and higher CHA2DS2-VASc score were more likely to be underdosed, but there was no significant difference in outcomes including stroke/TIA/embolism and bleeding.


Asunto(s)
Fibrilación Atrial/tratamiento farmacológico , Inhibidores del Factor Xa/administración & dosificación , Errores de Medicación/estadística & datos numéricos , Factores de Edad , Anciano , Anciano de 80 o más Años , Fibrilación Atrial/complicaciones , Comorbilidad , Dabigatrán/administración & dosificación , Cálculo de Dosificación de Drogas , Embolia/etiología , Embolia/prevención & control , Femenino , Hemorragia/inducido químicamente , Hemorragia/epidemiología , Humanos , Ataque Isquémico Transitorio/etiología , Ataque Isquémico Transitorio/prevención & control , Masculino , Persona de Mediana Edad , Pirazoles/administración & dosificación , Piridonas/administración & dosificación , Factores de Riesgo , Rivaroxabán/administración & dosificación , Factores Sexuales
6.
Med. infant ; 27(2): 133-137, Diciembre 2020. Tab, ilus
Artículo en Español | LILACS, BINACIS, UNISALUD | ID: biblio-1148492

RESUMEN

Introducción: Los errores de medicación (EM) causan una elevada morbimortalidad y generan costos innecesarios. El servicio de emergencias (SE) presenta un mayor riesgo de EM que otras áreas. El desarrollo de una herramienta que estandarice el uso de fármacos podría mejorar la seguridad y el proceso de medicación. Objetivos: Evaluar las mejoras en el proceso de medicación mediante el uso de tablas de medicación (TM) durante la atención del estado epiléptico (EE). Materiales y métodos: Se realizó un estudio de tipo antes y después no controlado. La intervención fue el desarrollo e implementación de TM. Se relevó in situ la prescripción, preparación y administración de fármacos incluidos en las TM durante segunda quincena de Octubre y mes de Noviembre 2016, previo a la implementación de la herramienta, y en el mismo período de 2017, luego de la inducción e implementación de las tablas. Se registraron los EM y se categorizaron de acuerdo a la etapa del proceso en que ocurrieron. Resultados: En el período pre-intervención se realizaron 14 registros, 86% (12) tenía al menos un error; 57% (8) errores en la etapa de prescripción, 57% (8) en la de preparación y 21% (3) en la de administración. En el período post-intervención se realizaron 17 registros, 12% (2) tenía por lo menos un EM. No se registraron errores en la fase de prescripción, hubo 12% (2) de errores de preparación y 6% (1) de administración. Conclusión: La implementación de las TM para la estandarización del uso de fármacos en EE resultó una medida muy positiva, mejorando la seguridad en el proceso de medicación (AU)


Introduction: Medication errors (ME) are associated with high morbidity mortality and lead to unnecessary costs. The risk of ME is higher at the emergency department (ED) than in other areas. Developing a tool that standardizes drug use may improve safety and medication processes. Objectives: To evaluate improvements in the medication process by using medication cards (MCs) during status epilepticus (SE) care. Materials and methods: An uncontrolled before-and-after study was conducted. The intervention was the development and implementation of MCs. The in situ prescription, preparation, and administration of drugs included in the MCs was recorded during the second half of October and November 2016, prior to the implementation of the tool, and in the same period of 2017, after the introduction and implementation of the MCs. ME were recorded and categorized according to the stage of the process in which they occurred. Results: In the pre-intervention period 14 episodes were recorded; in 86% (12) at least one error occurred; 57% (8) were ME in the prescription stage, 57% (8) were ME in the preparation stage, and 21% (3) were ME in the administration stage. In the post-intervention period 17 errors were recorded, in 12% (2) at least one ME occurred. No errors were recorded in the prescription stage, 12% (2) were preparation errors, and 6% (1) administration errors. Conclusion: The implementation of MCs for the standardization of medications used in the RU was successful, improving safety in the medication process (AU)


Asunto(s)
Humanos , Lactante , Preescolar , Niño , Adolescente , Estado Epiléptico/tratamiento farmacológico , Equipo Hospitalario de Respuesta Rápida/estadística & datos numéricos , Errores de Medicación/prevención & control , Errores de Medicación/estadística & datos numéricos , Sistemas de Medicación en Hospital/organización & administración , Anticonvulsivantes/administración & dosificación , Mejoramiento de la Calidad , Seguridad del Paciente
7.
Artículo en Inglés | MEDLINE | ID: mdl-32796648

RESUMEN

BACKGROUND: In order to explore the possible association between chronotype and risk of medication errors and chronotype in Italian midwives, we conducted a web-based survey. The questionnaire comprised three main components: (1) demographic information, previous working experience, actual working schedule; (2) individual chronotype, either calculated by Morningness-Eveningness Questionnaire (MEQ); (3) self-perception of risk of medication error. RESULTS: Midwives (n = 401) responded "yes, at least once" to the question dealing with self-perception of risk of medication error in 48.1% of cases. Cluster analysis showed that perception of risk of medication errors was associated with class of age 31-35 years, shift work schedule, working experience 6-10 years, and Intermediate-type MEQ score. CONCLUSIONS: Perception of the risk of medication errors is present in near one out of two midwives in Italy. In particular, younger midwives with lower working experience, engaged in shift work, and belonging to an Intermediate chronotype, seem to be at higher risk of potential medication error. Since early morning hours seem to represent highest risk frame for female healthcare workers, shift work is not always aligned with individual circadian preference. Assessment of chronotype could represent a method to identify healthcare personnel at higher risk of circadian disruption.


Asunto(s)
Ritmo Circadiano , Errores de Medicación/estadística & datos numéricos , Partería , Prioridad del Paciente , Horario de Trabajo por Turnos/efectos adversos , Sueño/fisiología , Estudios Transversales , Femenino , Humanos , Internet , Italia , Embarazo , Encuestas y Cuestionarios
8.
Paediatr Drugs ; 22(5): 551-560, 2020 Oct.
Artículo en Inglés | MEDLINE | ID: mdl-32627136

RESUMEN

BACKGROUND: To protect children from harm, clinicians, educators, and patient safety champions need information to direct improvement efforts. Critical incident data could provide this but are often disregarded as a source of evidence because under-reporting makes them an inaccurate measure of error rates. OBJECTIVE: Our aim was to identify key targets for pediatric healthcare quality improvement. The objective was to evaluate the types, characteristics, and areas of risk within reported medication errors in pediatric patients. METHODS: We conducted a retrospective study of a large regional dataset of 1522 pediatric medication errors reported from secondary care between 2011 and 2015, including all hospitals and community pediatric settings in Northern Ireland. The following characteristics were included: error severity, patient age, drug involved, error type, and area of practice. Two academic pediatricians, a senior medicines governance pharmacist, a Reader in Pharmacy Practice, and a Professor of Medical Education analyzed the data. Validity checks included comparing the findings against key published literature and discussion by a practitioner panel representing five multidisciplinary stakeholder groups. RESULTS: Neonates, particularly in intensive care, were implicated in 19% of all errors. The medications most represented in risk were antimicrobials, paracetamol, vaccines, and intravenous fluids. The error types most implicated were dosing errors (32%) and omissions (21%). CONCLUSIONS: Incident reports identified neonates, a shortlist of drugs, and specific error types, associated with modifiable behaviors, as priority improvement targets. These findings direct further study and inform intervention development, such as specific training in calculations to prevent dosing errors. Involving experienced practitioners both endorsed the findings and engaged the practice community in their future implementation. The utility of incident reports to direct improvement efforts may offset the limitations in their representativeness.


Asunto(s)
Errores de Medicación/estadística & datos numéricos , Mejoramiento de la Calidad , Adolescente , Niño , Preescolar , Humanos , Lactante , Recién Nacido , Errores de Medicación/prevención & control , Programas Nacionales de Salud , Irlanda del Norte , Seguridad del Paciente , Estudios Retrospectivos , Riesgo
9.
Epidemiol Health ; 42: e2020030, 2020.
Artículo en Inglés | MEDLINE | ID: mdl-32512668

RESUMEN

OBJECTIVES: Medication errors (MEs) made by nurses are the most common errors in emergency departments (EDs). Identifying the factors responsible for MEs is crucial in designing optimal strategies for reducing such occurrences. The present study aimed to review the literature describing the prevalence and factors affecting MEs among emergency ward nurses in Iran. METHODS: We searched electronic databases, including the Scientific Information Database, PubMed, Cochrane Library, Web of Science, Scopus, and Google Scholar, for scientific studies conducted among emergency ward nurses in Iran. The studies were restricted to full-text, peer-reviewed studies published from inception to December 2019, in the Persian and English languages, that evaluated MEs among emergency ward nurses in Iran. RESULTS: Eight studies met the inclusion criteria. Most of the nurses (58.9%) had committed MEs only once. The overall mean rate of MEs was 46.2%, and errors made during drug administration accounted for 41.7% of MEs. The most common type of administration error was drug omission (17.8%), followed by administering drugs at the wrong time (17.5%) and at an incorrect dosage (10.6%). The lack of an adequate nursing workforce during shifts and improper nurse-patient ratios were the most critical factors affecting the occurrence of MEs by nurses. CONCLUSIONS: Despite the increased attention on patient safety in Iran, MEs by nurses remain a significant concern in EDs. Therefore, nurse managers and policy-makers must take adequate measures to reduce the incidence of MEs and their potential negative consequences.


Asunto(s)
Enfermería de Urgencia , Servicio de Urgencia en Hospital , Errores de Medicación/estadística & datos numéricos , Humanos , Irán
10.
PLoS One ; 15(6): e0233486, 2020.
Artículo en Inglés | MEDLINE | ID: mdl-32497110

RESUMEN

BACKGROUND: Most residents in elderly care homes in Sri Lanka do not receive formal, on-site, patient care services. OBJECTIVE: To evaluate the appropriateness of prescribing, dispensing, administration, and storage practices of medication used by residents in selected elderly care homes in Colombo District, Sri Lanka. METHODOLOGY: This was a prospective, cross-sectional, multi-center study of 100 residents with chronic, non-communicable diseases, who resided in nine selected elderly care homes in Sri Lanka. Medication histories were obtained from each resident/caregiver and the appropriateness of medications in their current prescription was reviewed using standard treatment guidelines. Prescriptions were cross-checked against respective dispensing labels to identify dispensing errors. Medication administration was directly observed on two separate occasions per resident for accuracy of administration, and matched against the relevant prescription instructions. Medication storage was also observed in terms of exposure to temperature and sunlight, the suitability of container, and adequacy of separation if using multiple medications. RESULTS: The mean age of residents was 70±10.5 years and the majority were women (72%). A total of 168 errors out of 446 prescriptions were identified. The mean number of prescribing errors per resident was 1.68±1.23 [median, 2.00 (1.00-3.00)]. Inappropriate dosing frequencies were the highest (37.5%;63/168), followed by missing or inappropriate medications (31.5%;53/168). The mean number of dispensing errors per resident was 15.9±13.1 [median, 14.0 (6.00-22.75)] with 3.6 dispensing errors per every medication dispensed. Mean administration errors per resident was 0.95±1.5 [median, 0.00 (0.00-1.00)], with medication omissions being the predominant error (50.5%;48/95). Another lapse was incorrect storage of medications (143 storage errors), and included 83 medications not properly separated from each other (58.0%). CONCLUSION: Multiple errors related to prescribing, dispensing, administration, and storage were identified amongst those using medication in elderly care homes. Services of a dedicated consultant pharmacist could improve the quality of medication use in elderly care homes in Sri Lanka.


Asunto(s)
Errores de Medicación/estadística & datos numéricos , Administración del Tratamiento Farmacológico , Casas de Salud , Seguridad del Paciente , Anciano , Anciano de 80 o más Años , Estudios Transversales , Interacciones Farmacológicas , Almacenaje de Medicamentos , Femenino , Humanos , Prescripción Inadecuada , Masculino , Sistemas de Medicación/organización & administración , Sistemas de Medicación/estadística & datos numéricos , Administración del Tratamiento Farmacológico/organización & administración , Administración del Tratamiento Farmacológico/estadística & datos numéricos , Persona de Mediana Edad , Estudios Prospectivos , Garantía de la Calidad de Atención de Salud , Sri Lanka
11.
J Clin Nurs ; 29(17-18): 3403-3413, 2020 Sep.
Artículo en Inglés | MEDLINE | ID: mdl-32531850

RESUMEN

AIMS AND OBJECTIVES: To evaluate a bundle of interventions, developed and implemented by nurses, to reduce medication administration error rates and improve nurses' medication administration practice. BACKGROUND: Medication administration errors are a problematic issue worldwide, despite previous attempts to reduce them. Most interventions to date focus on isolated elements of the medication process and fail to actively involve nurses in developing solutions. DESIGN: An Action Research (AR) three-phase quantitative study. METHODS: Phase One aimed to build an overall picture of medication practice. Phase Two aimed to develop and implement targeted interventions. During this phase, the research team recruited six clinical paediatric nurses to be part of the AR Team. Five interventions were developed and implemented by the clinical nurses during this phase. The interventions were evaluated in Phase Three. Data collection included medication incident data, medication policy audits based on hospital medication policy and Safety Attitudes Questionnaire. Quantitative analysis was undertaken. The Standards for QUality Improvement Reporting Excellence (SQUIRE) checklist was followed in reporting this study. RESULTS: Postimplementing the interventions, medication error rates were reduced by 56.9% despite an increase in the number of patient admissions and in the number of prescribed medications. The rate of medication errors per 1,000 prescribed medications significantly declined from 2014 to 2016. The ward nurses were more compliant with the policy in postintervention phase than preintervention phase. The improvement in SAQ was reported in five of the seven domains. CONCLUSION: Clinically based nurse's participation in action research enabled practice reflection, development and implementation of a bundle of interventions, which led to a change in nursing practice and subsequent reduction in medication administration error rates. Active engagement of nurses in research empowers them to find solutions that are tailored to their own practice culture and environment.


Asunto(s)
Errores de Medicación/prevención & control , Enfermeras Pediátricas/organización & administración , Personal de Enfermería en Hospital/organización & administración , Niño , Prescripciones de Medicamentos/estadística & datos numéricos , Femenino , Hospitalización/estadística & datos numéricos , Humanos , Masculino , Errores de Medicación/enfermería , Errores de Medicación/estadística & datos numéricos , Oportunidad Relativa , Mejoramiento de la Calidad , Encuestas y Cuestionarios
12.
Nursing ; 50(5): 61-62, 2020 May.
Artículo en Inglés | MEDLINE | ID: mdl-32332508

RESUMEN

Some nurses continue to routinely dilute I.V. push medications, a practice associated with a high risk of errors. This article reviews correct practices for administering I.V. push medications.


Asunto(s)
Quimioterapia/enfermería , Inyecciones Intravenosas/enfermería , Errores de Medicación/enfermería , Humanos , Inyecciones Intravenosas/efectos adversos , Inyecciones Intravenosas/métodos , Errores de Medicación/estadística & datos numéricos , Guías de Práctica Clínica como Asunto , Pautas de la Práctica en Enfermería/normas
13.
BMC Health Serv Res ; 20(1): 276, 2020 Apr 03.
Artículo en Inglés | MEDLINE | ID: mdl-32245459

RESUMEN

BACKGROUND: Medical-incident reporting (MIR) ensures patient safety and delivery of quality of care by minimizing unintentional harm among health care providers. We explored medical-incident reporting practices, perceived barriers and motivating factors among health care providers at Mbarara Regional Referral Hospital (MRRH). METHODS: We conducted a cross-sectional descriptive study on 158 health provider at Mbarara Regional Referral Hospital (MRRH), Western Uganda. Data was gathered using a structured questionnaire and analyzed with SPSS. The chi-square was used to determine factors associated with MIR at MRRH. RESULTS: The results showed that there was no formal incident reporting structure. However the medical-incidences identified were: medication errors (89.9%), diagnostic errors (71.5%), surgical errors (52.5%) and preventive error (47.7%). The motivating factors of MIR were: establishment of a good communication system, instituting corrective action on the reported incidents and reinforcing health workers knowledge on MIR (p-value 0.004); presence of effective organizational systems like: written guidelines, practices of open door policy, no blame approach, and team work were significantly associated with MIR (p-value 0.000). On the other hand, perceived barriers to MIR were: lack of knowledge on incidents and their reporting, non-existence of an incident reporting team and fear of being punished (p- value 0.669). CONCLUSION: Medical Incident Reporting at MRRH was sub-optimal. Therefore setting up an incident management team and conducting routine training MIR among health care workers will increase patient safety.


Asunto(s)
Errores Médicos/estadística & datos numéricos , Personal de Hospital , Gestión de Riesgos/estadística & datos numéricos , Actitud del Personal de Salud , Estudios Transversales , Errores Diagnósticos/estadística & datos numéricos , Humanos , Entrevistas como Asunto , Errores de Medicación/estadística & datos numéricos , Motivación , Política Organizacional , Seguridad del Paciente , Encuestas y Cuestionarios , Centros de Atención Terciaria/organización & administración , Uganda
14.
Aten. prim. (Barc., Ed. impr.) ; 52(4): 233-239, abr. 2020. tab, graf
Artículo en Español | IBECS | ID: ibc-197231

RESUMEN

INTRODUCCIÓN Y OBJETIVO: El objetivo del presente estudio es describir los errores de medicación (EM) notificados en atención primaria analizando el ámbito, el daño y las causas, y orientando el análisis a las medidas para prevenir estos errores. MATERIAL Y MÉTODOS: Ámbito: Atención primaria. Servicio Madrileño de Salud. 2016. DISEÑO: Estudio descriptivo transversal. PARTICIPANTES: Todas las notificaciones de EM realizadas desde los centros de salud en el sistema de notificación de incidentes de seguridad entre el 1 de enero y el 17 de noviembre de 2016 (n = 1.839). Mediciones principales: Ámbito donde ocurrió el error, daño real, daño potencial y causa del error. Fueron clasificadas por un investigador. Se comprobó la concordancia con otro investigador. RESULTADOS: En el ámbito del centro de salud ocurrieron el 47% (IC95%: 44,8-49,3%) de los EM y en el entorno del paciente el 26,5% (IC95%: 24,5-28,6%). El 27,5% (IC95%: 24,1-30,8%) de los EM tenían potencialidad de daño grave. En el ámbito del centro de salud, la causa más frecuente fue la prescripción inadecuada: 27,4% (IC95%: 24,4-30,4%). En el entorno del paciente, la causa más frecuente fue el fallo en la comunicación profesional-paciente: 66% (IC95%: 61,8-70,2%), seguida por equivocaciones y despistes del paciente. CONCLUSIONES: La mitad de los errores de medicación notificados desde atención primaria tiene lugar en el centro de salud mientras que los EM del paciente son la cuarta parte. Uno de cada 4 es un error potencialmente grave. Las causas más importantes son la prescripción inadecuada (incluyendo indicación o dosis incorrecta, interacciones, contraindicaciones y alergias), los fallos en la comunicación profesional-paciente y los despistes en la autoadministración del paciente. Parece prioritario implantar sistemas de ayuda a la prescripción, prácticas seguras efectivas en comunicación profesional-paciente y ayudas que eviten los despistes en la autoadministración del paciente


INTRODUCTION AND OBJECTIVES: Aim of this study is to determine the setting, causes, and the harm of medication errors (ME) which are notified by Primary Health Care. MATERIAL AND METHODS: SETTING: Primary Care Regional Health Service of Madrid. 2016. DESIGN: Descriptive and cross-sectional study. PARTICIPANTS: All ME (1,839) which were notified by Primary Care Centres by notification system of safety incidents between January 1st 2016 and November 17th 2016. MAIN MEASUREMENTS: Setting, real harm, potential harm, and cause of error. These items were classified by one researcher. Concordance was checked with another researcher. RESULTS: Just under half (47%) (95% CI: 44.8%-49.3%) of ME occurred in Primary Care Centre, 26.5% (95% CI: 24.5%-28.6%) of ME were patient medication errors, and 27.5% (95% CI: 24.1%-30.8%) of ME were potential severe harm errors. Prescribing errors were the cause of most ME in Primary Care Centre [27.4% (95% CI: 24.4%-30.4%)]. Communication between patients and doctors were the cause of most patient medication errors [66% (95% CI: 61.8%-70.2%)]. Patient mistakes and forgetfulness were also causes of patient medication errors. CONCLUSIONS: Half of all mediation errors hppened at Primary Care Center while one quarter of them were patient medication errors. One quarter of all ME were potential severe harm errors. The main causes were prescribing errors, failure of communication between patients and doctors, and patient mistakes and forgetfulness. Prescribing aid systems, communication improvements and patients aids should be implemented


Asunto(s)
Humanos , Masculino , Femenino , Adulto , Persona de Mediana Edad , Anciano , Anciano de 80 o más Años , Errores de Medicación/estadística & datos numéricos , Atención Primaria de Salud , Notificación , Estudios Transversales
15.
Enferm. glob ; 19(58): 68-81, abr. 2020. tab, graf
Artículo en Español | IBECS | ID: ibc-195551

RESUMEN

OBJETIVO: Realizar un Análisis Multimodal de fallas y efectos para identificar prospectivamente los riesgos relacionados a la fase de la preparación y dispensación de medicamentos quimioterápicos en una unidad ambulatoria de un centro de referencia en oncología. MÉTODOS: Se utilizaron las seis primeras etapas del Análisis Multimodal de fallas y Efectos: identificar las situaciones peligrosas y montar un equipo; definir el proceso a ser analizado describiendo gráficamente; aplicar lluvia de ideas buscando identificar modos de fallas; priorizar los modos de fallas y realizar análisis de riesgos; identificar las causas potenciales de los modos de fallo y volver a dibujar el proceso. RESULTADOS: Se identificaron diecisiete modos de falla, siendo dos clasificados como de alto riesgo: cambiar la ventana de salida del medicamento y cálculo erróneo de la dosis de medicamento intratecal. CONCLUSIONES: Se identificaron los posibles modos de falla que se relacionaban al proceso analizado, además, fue posible definir causas potenciales para la existencia de esos riesgos


AIM: Conduct a Failure Mode and Effect Analysis (FMEA) to prospectively identify the risks related to the preparation and dispensation of chemotherapy drugs at an outpatient unit of a reference center in oncology. METHODS: The first six stages of Failure Mode and Effect Analysis were used to identify dangerous situations and assemble a team; define the process to be analyzed and describe it graphically; apply a host of ideas to identify failure modes; prioritize failure modes and conduct risk analysis; identify potential causes of failure modes and redesign the process. RESULTS: Seventeen failure modes were identified, two of which were classified as high risk: changing the output window for the drug and miscalculating the intrathecal drug dose. CONCLUSIONS: The possible failure modes related to the process analyzed were identified; in addition, it was possible to define potential causes of these risks


OBJETIVO: Realizar uma Análise Multimodal de Falhas e Efeitos para identificar prospectivamente os riscos relacionados à fase do preparo e dispensação de medicamentos quimioterápicos em uma unidade ambulatorial de um centro de referência em oncologia. MÉTODOS: Foram utilizadas as seis primeiras etapas da Análise Multimodal de Falhas e Efeitos: identificar as situações perigosas e montar uma equipe; definir o processo a ser analisado descrevendo graficamente; aplicar chuva de ideias buscando identificar modos de falhas; priorizar os modos de falhas e realizar análise dos riscos; identificar causas potenciais dos modos de falha e redesenhar o processo. RESULTADOS: Foram identificados dezessete modos de falha, sendo dois classificados como de alto risco: trocar a janela de saída do medicamento e cálculo errado da dose de medicamento intratecal. CONCLUSÕES: Foram identificados os possíveis modos de falha que se relacionavam ao processo analisado, além disso, foi possível definir causas potenciais para a existência desses riscos


Asunto(s)
Humanos , Protocolos de Quimioterapia Combinada Antineoplásica/farmacología , Antineoplásicos/farmacología , Efectos Colaterales y Reacciones Adversas Relacionados con Medicamentos/epidemiología , Análisis de Modo y Efecto de Fallas en la Atención de la Salud/estadística & datos numéricos , Medicamentos de Referencia , Quimioterapia Combinada/métodos , Errores de Medicación/estadística & datos numéricos , Seguridad del Paciente/estadística & datos numéricos , Daño del Paciente/clasificación , Medición de Riesgo/métodos
16.
Nurse Educ Today ; 87: 104359, 2020 Apr.
Artículo en Inglés | MEDLINE | ID: mdl-32058883

RESUMEN

BACKGROUND: Medication administration errors are common among new nurses. Nursing students might be less willing to speak up about errors because of a lack of knowledge and experience. OBJECTIVES: To examine the effects of simulation training and problem-based scenarios on speaking up about medication errors among graduating nursing students. DESIGN: Prospective, controlled experimental study design. SETTING: A university four-year nursing program in Taiwan. PARTICIPANTS: In total, 93 graduating nursing students in their last semester were recruited. Sixty-six students who received both a problem-based scenario and medication administration simulation training comprised the experimental group, while 27 students who received problem-based scenarios alone comprised the control group. METHODS: Experimental group students underwent 2 h of simulation training. This training class was designed based on Kolb's experiential learning theory for knowledge development and speaking up about errors. Students in both groups administered medications in problem-based scenarios with eight embedded errors. Students' performance in speaking up about medication errors was directly observed and graded using an objective structured checklist. The McNeamer Chi-squared test, paired t-test, Z test, t-test, and Hedges' g effect size were conducted. RESULTS: The number of times participants spoke up about medication errors significantly improved in both the experimental group (pre-test: 2.05 ± 1.12 and post-test 6.14 ± 1.25, t = 22.85, p<0.001) and control group (pretest: 2.04 ± 1.16 and post-test: 4.26 ± 1.63, t = 6.33, p<0.001). However, after the intervention, the mean number of times participants spoke up about medication errors in the experimental group was significantly higher than that in the control group (t = 5.99, p<0.001) in the post-test. CONCLUSIONS: Simulation training exhibited more-significant improvements than problem-based scenarios. Nursing schools and hospitals should incorporate simulation training or at least problem-based scenarios to improve medication safety.


Asunto(s)
Competencia Clínica/normas , Errores de Medicación/estadística & datos numéricos , Aprendizaje Basado en Problemas , Entrenamiento Simulado , Estudiantes de Enfermería/estadística & datos numéricos , Adulto , Bachillerato en Enfermería , Femenino , Humanos , Masculino , Estudios Prospectivos , Desempeño de Papel , Facultades de Enfermería , Taiwán , Adulto Joven
17.
PLoS One ; 15(2): e0228868, 2020.
Artículo en Inglés | MEDLINE | ID: mdl-32027720

RESUMEN

OBJECTIVE: Limited evidence concerning the burden and predictors of omitted medication doses within mental health hospitals could severely limit improvement efforts in this specialist setting. This study aimed to determine the prevalence, nature and predictors of omitted medication doses affecting hospital inpatients in two English National Health Service (NHS) mental health trusts. METHODS: Over 6 data collection days trained pharmacy teams screened inpatient prescription charts for scheduled and omitted medication doses within 27 adult and elderly wards across 9 psychiatric hospitals. Data were collected for inpatients admitted up to two weeks prior to each data collection day. Omitted doses were classified as 'time critical' and 'preventable' based on established criteria. Omitted dose frequencies were presented with 95% confidence intervals (CI). Multilevel logistic regression analyses determined the predictors of omitted dose occurrence, with omission risks presented as adjusted odds ratios (OR) with 95% CI. RESULTS: 18,664 scheduled medication doses were screened for 444 inpatients and 2,717 omissions were identified, resulting in a rate of 14.6% (95% CI 14.1-15.1). The rate of 'time critical' omitted doses was 19.3% (95% CI 16.3-22.6%). 'Preventable' omitted doses comprised one third of all omissions (34.5%, 930/2694). Logistic regression analysis revealed that medicines affecting the central nervous system were 55% less likely to be omitted compared to all other medication classes (9.9% vs. 18.8%, OR 0.45 (0.40-0.52)) and that scheduled doses administered using non-oral routes were more likely to be omitted compared the oral route (inhaled OR 3.47 (2.64-4.57), topical 2.71 (2.11-3.46), 'other' 2.15 (1.19-3.90)). 'Preventable' dose omissions were more than twice as likely to occur for 'time critical' medications than non-time critical medications (50.4% vs. 33.8%, OR 2.24 (1.22-4.11)). CONCLUSIONS: Omitted medication doses occur commonly in mental health hospitals with 'preventable' omissions a key contributor to this burden. Important targets for remedial intervention have been identified.


Asunto(s)
Hospitales Psiquiátricos , Errores de Medicación/estadística & datos numéricos , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Fármacos del Sistema Nervioso Central/administración & dosificación , Femenino , Humanos , Pacientes Internos/estadística & datos numéricos , Modelos Logísticos , Masculino , Errores de Medicación/prevención & control , Sistemas de Medicación en Hospital/estadística & datos numéricos , Trastornos Mentales/tratamiento farmacológico , Persona de Mediana Edad , Análisis Multivariante , Prevalencia , Medicina Estatal , Reino Unido , Adulto Joven
18.
Comput Inform Nurs ; 38(5): 256-262, 2020 May.
Artículo en Inglés | MEDLINE | ID: mdl-32015260

RESUMEN

Medication administration using bar-code medication administration technology enhances the verification of medication administration rights. Nurses' compliance with bar-code medication administration procedure is essential to maximize the benefits. This study evaluated the current rate of nurses' compliance with bar-code medication administration use through direct observation. A descriptive design was used and 134 RNs were recruited from two public hospitals located in the middle region of Jordan. Compliance with bar-code medication administration was evaluated using an evidence-based checklist of 17 items. Participants' compliance with the bar-code medication administration was 55%, which had a significant positive correlation with their level of comfort using bar-code medication administration, usefulness, and ease of use, perceived job productivity, and overall rating of bar-code medication administration. Stakeholders can benefit from assessing end-user acceptance and perceptions regarding the bar-code medication administration technology to promote acceptance and compliance.


Asunto(s)
Adhesión a Directriz/normas , Enfermeras y Enfermeros/psicología , Adulto , Actitud del Personal de Salud , Procesamiento Automatizado de Datos/instrumentación , Procesamiento Automatizado de Datos/métodos , Femenino , Adhesión a Directriz/estadística & datos numéricos , Humanos , Jordania , Masculino , Errores de Medicación/prevención & control , Errores de Medicación/estadística & datos numéricos , Persona de Mediana Edad , Enfermeras y Enfermeros/estadística & datos numéricos , Estadísticas no Paramétricas
19.
Aten. prim. (Barc., Ed. impr.) ; 52(2): 77-85, feb. 2020. tab, graf
Artículo en Español | IBECS | ID: ibc-196823

RESUMEN

OBJETIVO: Estudiar si en pacientes mayores de 65años con tratamientos antihipertensivos e hipolipemiantes los cambios de fármacos bioequivalentes con diferente apariencia se asocian a un aumento de errores de uso y pérdida de adherencia al tratamiento. DISEÑO: Estudio observacional, longitudinal, prospectivo, de cohorte de 1año de seguimiento entre el 1 de enero de 2013 y el 31 de diciembre de 2014. Emplazamiento: Centros de Salud de la Comunidad de Madrid. PARTICIPANTES: Pacientes ≥ 65 años con diagnóstico de HTA (CIAP K86) y/o dislipidemia (CIAP T93) en tratamiento con enalapril y/o amlodipino y/o simvastatina. Mediciones principales: Se recogieron mediante entrevista en consulta variables sociodemográficas (edad, sexo, nivel de estudios), clínicas, adherencia (test de Morisky-Green y recuento directo), errores de medicación (número y tipo), cambios de fármacos y número, parámetros bioquímicos (colesterol total, colesterol HDL, colesterol LDL, triglicéridos) y variable combinada (error y/o adherencia). Se realizaron 5 visitas: una basal y 4 trimestrales. RESULTADOS: Se incluyeron 274 pacientes, edad media 72 (6,6) años, 47,8% mujeres. Presentaron algún cambio de medicamento 134 pacientes (48,9%), con una mediana de cambios de 3 (RIQ 1-5) y máximo de 11. El riesgo de presentar algún error o disminuir la adherencia estaba aumentado en expuestos a cambios en todas las visitas con RR 1,14 (1,16-1,69) al año de seguimiento. El error más frecuente fue la pérdida de dosis. Por cada cambio la probabilidad de un evento combinado aumenta en un 41%. CONCLUSIONES: Los cambios realizados entre fármacos bioequivalentes con diferente apariencia podrían aumentar el número de errores de medicación y disminuir la adherencia. Habría que realizar más estudios para valorar en qué medida afecta al control de la enfermedad. No se contempla el apartado intervención por tratarse de un estudio observacional


OBJECTIVE: To study whether the changes in bioequivalent drugs with different appearances are associated with an increase in lack of adherence and medication use errors, in patients > 65 years old treated with antihypertensive and lipid-lowering medications. DESIGN: Observational longitudinal prospective cohort study with a one-year follow-up period between 1 January 2013 and 31 December 2014. LOCATION: Primary Healthcare Centres in the Community of Madrid. PARTICIPANTS: Patients ≥ 65 years-old with a diagnosis of hypertension and/or dyslipidaemia receiving treatment with Enalapril and/or Amlodipine and/or Simvastatin. MAIN MEASUREMENTS: Variables collected during a Primary Care consultation by means of a personal interview were: sociodemographic (age, gender, level of education), clinical variables, adherence (Morisky-Green test and direct counting), medication errors (number and type), medication changes and number, analytical (total cholesterol, HDL-cholesterol, LDL-cholesterol, triglycerides) and combined variable (error and/or adherence). There were 1 baseline and 4 quarterly visits. RESULTS: The study included 274 patients with a mean age 72 (6.6) years, of whom 47.8% were female. Some medication changes were observed in 134 patients (48.9%), with a median of 3 (IQR 1-5) and a maximum of 11 changes. The risk of presenting with a medication use error or decreased adherence was increased in patients exposed to changes in all visits with RR 1.14 (1.16-1.69) at one year of follow-up. The most frequent error was the loss of dose. For each change in medication, the probability of a combined event increases by 41%. CONCLUSIONS: The changes made in bioequivalent drugs with different appearance could increase the number of medication use errors and decrease the adherence. More studies should be carried out to assess how much this affects the control of the disease. The intervention section is not considered because it is an observational study


Asunto(s)
Humanos , Masculino , Femenino , Anciano , Anciano de 80 o más Años , Amlodipino/uso terapéutico , Antihipertensivos/uso terapéutico , Etiquetado de Medicamentos , Embalaje de Medicamentos , Enalapril/uso terapéutico , Hiperlipidemias/tratamiento farmacológico , Hipertensión/tratamiento farmacológico , Hipolipemiantes/uso terapéutico , Cumplimiento de la Medicación/estadística & datos numéricos , Errores de Medicación/estadística & datos numéricos , Primeros Auxilios , Simvastatina/uso terapéutico , Enfermedad Crónica , Estudios de Seguimiento , Estudios Longitudinales , Estudios Prospectivos
20.
Trials ; 21(1): 26, 2020 Jan 06.
Artículo en Inglés | MEDLINE | ID: mdl-31907009

RESUMEN

BACKGROUND: According to WHO, medication error (ME) is a subject that requires attention at all levels of care to reduce severe and preventable damage related to medication use. Clinical pharmacy practice standards have been proposed around the world so that the pharmacist, as part of a multidisciplinary health team, can help improve patient safety; however, further evidence derived from adequate studies is needed to demonstrate this. This study aims to assess the effect of a clinical pharmacy practice model (CPPM) in preventing MEs associated with the medication use process. METHODS: A prospective, stepped-wedge, cluster-randomized, controlled trial with a duration of 14 months will be performed to compare the effect of a CPPM along with the usual care process of patients in the Pablo Tobón Uribe Hospital (Medellin, Colombia). The study is designed as a cluster-randomized controlled trial, involving five hospital wards (clusters) and 720 patients. Medical wards are allocated to interventions using a stepped-wedge design. Clusters are initially assigned to the control group. After a 2-month observation period, hospital clusters were randomly allocated to the intervention group. Study outcomes will be assessed at baseline and at 2, 4, 6, 8, 10, and 12 months after randomization. The primary outcome will be to assess the effect of a CPPM on the incidence of medication errors associated with the medication use process. Drug-related problems and factors that contribute to the occurrence of MEs will be assessed as secondary outcomes. Statistical analyses will be performed using a mixed model, with the treatment group and time as fixed effects and the clustering structure as a random effect. Statistical analysis will be performed using Pearson chi-square tests and Student's t-tests, and a P value < 0.05 will be considered statistically significant. DISCUSSION: As far as we know, this is the first stepped-wedge, cluster-randomized, controlled trial designed to assess the change of a CPPM on the incidence of medication errors in a hospital in Colombia, and it could generate valuable information about a standardized and patient-centered clinical pharmacy model to improve the safety of inpatient care. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03338725. Registered on 9 November 2017. The first patient was randomized on 2 February 2018. PROTOCOL VERSION: 0010112018JG.


Asunto(s)
Errores de Medicación/estadística & datos numéricos , Modelos Organizacionales , Seguridad del Paciente , Servicio de Farmacia en Hospital/organización & administración , Adulto , Niño , Análisis por Conglomerados , Colombia , Femenino , Humanos , Incidencia , Masculino , Errores de Medicación/prevención & control , Persona de Mediana Edad , Estudios Prospectivos , Ensayos Clínicos Controlados Aleatorios como Asunto
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