[Implemented actions in the Spanish National Health System to improve patient safety culture]. / Acciones desarrolladas para avanzar en seguridad del paciente en el Sistema Nacional de Salud español.

BACKGROUND: The Ministry of Health, Consumption and Social Welfare (MHCSW) since 2005 has been promoting, in collaboration with the Autonomous Communities (AC) and the Scientific Societies (SC), among them the Spanish Society for Healthcare Quality (SSHCQ), the Patient Safety Strategy (PSS). PSS 2015-2020 develops relevant aspects of patient safety (PS), such as risk management, reporting and learning systems (RLS), as well as promoting an adequate response when an adverse event (AE) unexpectedly occurs. The present work describes the current situation of the different AC in relation to these topics. MATERIAL AND METHODS: A Descriptive study, based on a survey developed ad hoc within the framework of the agreement between the MHCSW and SSHCQ, was conducted at national level. The questions' topics, prepared by consensus of the work team, considered the implementation of RLS and AE analysis, and legal protection for professionals involved in an AE in the AC. RESULTS: A total of 17 surveys were collected (16 AC and INGESA). All ACs had a RLS, a structure to support PS activities but very heterogeneous. Some ACs had a response plan to an AE and had established a coordination protocol with legal services to support patients and professionals involved in an AE. Some ACs had enacted some laws and regulations to facilitate PS culture. CONCLUSIONS: The ACs have risk management structures that lead the plans in PS, reporting and learning systems and have experience in the analysis of near miss and AE. However, a regulatory change that increases the legal safety of professionals to provide an adequate response to the AEs is a priority. This challenge should involve leaders of health organizations, scientific societies and professional associations, national and regional health authorities as it has been done in other European countries.

Grado de conocimiento de la campaña Compromiso por la Calidad y de las recomendaciones no hacer entre médicos de familia, pediatras y enfermería de Atención Primaria / Level of knowledge of Quality Commitment Campaign and of "do not do" recommendations amongst general practitioners, pediatricians and nursing Primary Care

Fundamento: Evaluar si la iniciativa campaña Compromiso por la Calidad (ICC) era suficientemente conocida entre profesionales de atención primaria (AP), y valorar el grado de conocimiento de determinadas recomendaciones de lo que no debiera hacerse dirigidas a profesionales de AP. Material y métodos: Estudio observacional basado en un muestreo de conveniencia a profesionales de medicina de familia (MF), pediatría (PED) y enfermería (ENF). Se formuló una pregunta directa sobre si se conocía la ICC y una serie de preguntas dicotómicas basadas en las recomendaciones No Hacer para valorar el nivel de conocimiento. Se consideró necesario un tamaño muestral mínimo de 288 profesionales por cada colectivo, considerando un error del 5%, nivel de confianza del 95% y p=0,75. El estudio de campo se realizó con la colaboración de diversos servicios de salud y organizaciones profesionales y científicas. Los datos se describieron como frecuencias o media (desviación típica), y se compararon mediante χ2/Fisher o ANOVA y t-test. Resultados: Respondieron 1.904 profesionales (936 MF, 682 PED y 286 ENF). De ellos, 828 (43,5%) conocían la ICC: 524 (56,0%) MF, 234 (34,3%) PED y 70 (24,5%) ENF (p<0,001). Respondieron correctamente a todas las preguntas 652 (69,7%) MF, 631 (92,5%) PED y 116 (40,6%) ENF. Cometieron significativamente más errores (p<0,001) quienes no conocían la ICC, trabajaban en el sector privado o no se consideraban responsables de la sobreutilización. Pese a no conocer la ICC, 60% MF y 90% PED contestaron correctamente a todas las preguntas del test. Conclusiones: ENF y MF podrían beneficiarse de una mayor difusión de la ICC. También quienes trabajan en el sector privado y quienes creen que los profesionales tienen escasa responsabilidad en la sobreutilización innecesaria

Background: To evaluate if the Quality Commitment Campaign (QCC) was sufficiently known among primary care professionals (PC), and second, to evaluate the knowledge about certain recommendations of what should not be done in PC. Methods: A observational study was conducted. General practitioners (GP), pediatricians (PED) and nursing (NUR) participated. A direct question was asked about whether QCC was known and a set of dichotomous questions based on the "do not do" recommendations to assess their knowledge. A sample size of 288 professionals from each group was the minimum required for a sampling error of 5%, 95% confidence level and p=0.75. The field study was conducted with the collaboration of health services and professional and scientific organizations. Data were described by frequencies and mean (standard deviation), and compared by means of χ2/Fisher or ANOVA and t-test. Results: A total of 1,904 professionals (936 GP, 682 PED and 286 NUR) answered. The QCC initiative was known by 828 (43.5%) professionals: 524 (56.0%) GP, 234 (34.3%) PED and 70 (24.5%) NUR (p<0.001). All the questions were correctly answered by 652 (69.7%) GP, 631 (92.5%) PED and 116 (40.6%) NUR. Significantly more mistakes (p<0.001) were made by those who did not know the QCC, worked in the private sector or were not considered responsible for overuse. Despite not knowing the QCC, 60% GP and 90% PED answered all the questions of the test correctly. Conclusions: NUR and GP could benefit from a greater diffusion of the QCC. As could those working in the private sector and those who believe that professionals have little responsibility for unnecessary overuse

[Level of knowledge of Quality Commitment Campaign and of "do not do" recommendations amongst general practitioners, pediatricians and nurses Primary Care]. / Grado de conocimiento de la campaña Compromiso por la Calidad y de las recomendaciones no hacer entre médicos de familia, pediatras y enfermería de Atención Primaria.

BACKGROUND: To evaluate if the Quality Commitment Campaign (QCC) was sufficiently known among primary care professionals (PC), and second, to evaluate the knowledge about certain recommendations of what should not be done in PC. METHODS: A observational study was conducted. General practitioners (GP), pediatricians (PED) and nursing (NUR) participated. A direct question was asked about whether QCC was known and a set of dichotomous questions based on the "do not do" recommendations to assess their knowledge. A sample size of 288 professionals from each group was the minimum required for a sampling error of 5%, 95% confidence level and p=0.75. The field study was conducted with the collaboration of health services and professional and scientific organizations. Data were described by frequencies and mean (standard deviation), and compared by means of ?2/Fisher or ANOVA and t-test. RESULTS: A total of 1,904 professionals (936 GP, 682 PED and 286 NUR) answered. The QCC initiative was known by 828 (43.5%) professionals: 524 (56.0%) GP, 234 (34.3%) PED and 70 (24.5%) NUR (p<0.001). All the questions were correctly answered by 652 (69.7%) GP, 631 (92.5%) PED and 116 (40.6%) NUR. Significantly more mistakes (p<0.001) were made by those who did not know the QCC, worked in the private sector or were not considered responsible for overuse. Despite not knowing the QCC, 60% GP and 90% PED answered all the questions of the test correctly. CONCLUSIONS: NUR and GP could benefit from a greater diffusion of the QCC. As could those working in the private sector and those who believe that professionals have little responsibility for unnecessary overuse.

[Proposals for the study of the second victim phenomenon in Spanish Primary Care Centres and Hospitals]. / Propuestas para el estudio del fenómeno de las segundas víctimas en España en atención primaria y hospitales.

OBJECTIVE: To identify the Spanish studies conducted since 2014 on second victims. Its main objective was to identify a global response to the second victim problem, assessing the impact of adverse events (AE) on caregivers and developing of a set of tools to reduce their impact. METHOD: Descriptive studies in which a sample of managers and safety coordinators from Hospitals and Primary Care were surveyed to determine the activities being carried out as regards second victims, as well as a sample of health professionals to describe their experience as a second victims. Qualitative studies are included to design a guide of recommended actions following an AE, an online awareness program on this phenomenon, an application (app) with activities on safety that are the responsibility of the managers, and a web tool for the analysis of AEs. RESULTS: A total of 1,493 professionals (managers, safety coordinators and caregivers) from eight Spanish regions participated. The guide of recommendations, the online program, and the developed applications are accessible on the website: www.segundasvictimas.es, which has received more than 2,500 visits in one year. DISCUSSION: Study results represent a starting point in the study of the second victim phenomenon in Spain. The tools developed raise the awareness of the medical healthcare community about this problem, and provide professionals with basic skills to manage the impact of AEs.

Propuestas para el estudio del fenómeno de las segundas víctimas en España en atención primaria y hospitales / Proposals for the study of the second victim phenomenon in Spanish primary care centres and hospitals

Objetivo. Identificar los enfoques metodológicos y avances de un conjunto de estudios que se han realizado en España desde 2014 en la línea de investigación sobre segundas víctimas, mediante la evaluación del impacto de los eventos adversos (EA) en los profesionales sanitarios. Elaborar un conjunto de herramientas de ayuda para reducir su impacto. Método. Estudio descriptivo en el que se encuestó a directivos y coordinadores de seguridad de hospitales y atención primaria para conocer qué actividades se estaban llevando a cabo en materia de segundas víctimas, y a profesionales asistenciales para describir su posible experiencia como segundas víctimas, junto a estudios cualitativos para diseñar una guía de acciones recomendadas tras un EA, un programa online de sensibilización sobre este fenómeno, una app con actividades en seguridad responsabilidad de los directivos y una herramienta web para el análisis de los EA. Resultados. Participaron 1.493 profesionales (directivos, coordinadores de seguridad y personal asistencial) de 8 comunidades autónomas. La guía de recomendaciones, el programa online y las aplicaciones desarrolladas se encuentran accesibles en el sitio web: www.segundasvictimas.es, que recibió más de 2.500 visitas en un año. Discusión. Los resultados del estudio representan un punto de partida en el estudio del fenómeno de las segundas víctimas en España. Las herramientas desarrolladas sensibilizan a la comunidad sanitaria acerca de esta problemática y dotan a los profesionales de habilidades para gestionar el impacto de los EA (AU)

Objective. To identify the Spanish studies conducted since 2014 on second victims. Its main objective was to identify a global response to the second victim problem, assessing the impact of adverse events (AE) on caregivers and developing of a set of tools to reduce their impact. Method. Descriptive studies in which a sample of managers and safety coordinators from Hospitals and Primary Care were surveyed to determine the activities being carried out as regards second victims, as well as a sample of health professionals to describe their experience as a second victims. Qualitative studies are included to design a guide of recommended actions following an AE, an online awareness program on this phenomenon, an application (app) with activities on safety that are the responsibility of the managers, and a web tool for the analysis of AEs. Results. A total of 1,493 professionals (managers, safety coordinators and caregivers) from eight Spanish regions participated. The guide of recommendations, the online program, and the developed applications are accessible on the website: www.segundasvictimas.es, which has received more than 2,500 visits in one year. Discussion. Study results represent a starting point in the study of the second victim phenomenon in Spain. The tools developed raise the awareness of the medical healthcare community about this problem, and provide professionals with basic skills to manage the impact of AEs (AU)

Compliance with quality prescribing indicators linked to financial incentives: what about not incentivized indicators?: an observational study.

OBJECTIVE: The aims of this study were to investigate whether general practitioners (GPs) who complied with quality prescribing indicators included in the pay-for-performance programmes also complied with quality prescribing indicators which are not linked to incentives and to compare the prescribing behaviour between those GPs who showed compliance with quality prescribing indicators linked to financial incentives and those who did not. DESIGN AND METHODOLOGY: This was a descriptive cross-sectional study which was conducted in 2007 in the Aljarafe Primary Care Area (Andalusia, Spain) and involved 37 Health Care Centres and 176 GPs. The main outcome was the results of a comparison of six quality prescribing indicators linked to incentives and 14 quality prescribing indicators not linked to incentives. The chi-square test was used to compare qualitative variables. Quantitative variables were tested using Student's t test upon confirmation of normality. RESULTS: Those GPs showing compliance with the indicators included in the pay-for performance programme showed low levels of compliance with quality prescribing indicators that were unincentivised. With respect to compliance with the indicators not linked to financial incentives, we found no statistical difference between GPs who showed compliance with incentivised indicators (n = 57) and those showing non-compliance (n = 112) in terms of drug selection, with the exception of the selection of second- and third-line antibiotics and antihistamines, nor in terms of the appropriate use of drugs linked to patient's clinical conditions. CONCLUSIONS: The compliance of GPs showing compliance with quality prescribing indicators included in pay-for-performance programmes was not better than that of those who showed no compliance with other relevant quality prescribing indicators not linked to financial incentives.

Adecuación de la prescripción de beta-adrenérgicos de acción prolongada: resultados de una intervención en Atención Primaria / Quality prescribing of long-acting beta-agonists. Results of an intervention in Primary Care

Objetivo. Evaluar una intervención destinada a mejorar la adecuación de la prescripción de beta-adrenérgicos de acción larga (BAAL) en Atención Primaria. Material y métodos. Diseño: Estudio cuasi-experimental antes-después sin grupo control. Ámbito: Distrito de Atención Primaria (Servicio Andaluz de Salud). Sujetos: Médicos de familia con prescripciones de BAAL sin corticoides inhalados (CTi), que trabajaron más del 40% de los días hábiles del periodo estudiado. Unidad de estudio: Pacientes con prescripciones de BAAL sin CTi, seleccionados mediante muestreo aleatorio simple (fiabilidad 95%, precisión 5%). Intervenciones: Envío de carta y boletín con recomendaciones sobre uso adecuado de BAAL y la relación de pacientes con prescripciones inadecuadas. Variables: Adecuación de la prescripción de BAAL a las indicaciones autorizadas en fichas técnicas. En relación con los pacientes, se analizaron edad, sexo, tipo de BAAL y diagnóstico. Fuentes: Sistema de información de facturación de recetas e historia clínica informatizada. Resultados. Antes de la intervención, el porcentaje de inadecuación fue del 70,3%. Un 51,8% de los pacientes tenían una indicación de BAAL sin CTi no autorizada. El 18,5% no tenía registrado en su historia clínica diagnósticos relacionados con patologías respiratorias. Tras la intervención, el porcentaje de inadecuación pasó a ser del 4,5%, debido principalmente a la actualización de los tratamientos (retirada de BAAL o adición de CTi). Conclusiones. Existe un bajo grado de adecuación de la utilización de BAAL en Atención Primaria. El envío de material educativo con la relación de pacientes con prescripciones inadecuadas es una estrategia eficaz para mejorar los hábitos de prescripción en patologías respiratorias(AU)

Objective. To assess an intervention aimed to reduce inappropriate prescribing of long-acting beta-agonists (LABA) in Primary Care. Material and methods; Design Quasi-experimental pre/post study without control group. Setting: Aljarafe Primary Health Care Area (Seville, Spain). Participants: General practitioners with LABA prescriptions without inhaled corticosteroids (iCT), who worked more than 40% of working days in the study period. Study unit: Simple randomised sample of patients with LABA prescriptions without iCT. Interventions: Mailing educational material with recommendations on the appropriate use of LABA and a list of their patients with inappropriate prescriptions. Main measurement: Appropriateness of LABA prescriptions as indicated in the Product Summary Characteristics. Patient age, sex, type of LABA and diagnoses were analysed. Sources: An information system for billing computerized prescriptions and medical history. Results. Before intervention, prescriptions were inappropriate in 70.3% of patients, and 51.8% received LABA without iCT for unapproved conditions. A diagnosis associated with a respiratory condition was not recorded in the Computerised Medical Records of 18.5% of the patients. After intervention, the percentage of inappropriate prescriptions in the sample dropped to 4.5%, mainly due to a review of the treatment (LABA cessation or iCT addition). Conclusions. There is a high level of inappropriate use of LABA in Primary Health Care. Mailing educational materials combined with the list of patients with an inappropriate LABA prescription to general practitioners seems to be an effective strategy to improve quality prescribing in respiratory pathologies(AU)

[Quality prescribing of long-acting beta-agonists. Results of an intervention in Primary Care]. / Adecuación de la prescripción de beta-adrenérgicos de acción prolongada: resultados de una intervención en Atención Primaria.

OBJECTIVE: To assess an intervention aimed to reduce inappropriate prescribing of long-acting beta-agonists (LABA) in Primary Care. MATERIAL AND METHODS; DESIGN: Quasi-experimental pre/post study without control group. SETTING: Aljarafe Primary Health Care Area (Seville, Spain). PARTICIPANTS: General practitioners with LABA prescriptions without inhaled corticosteroids (iCT), who worked more than 40% of working days in the study period. Study unit: Simple randomised sample of patients with LABA prescriptions without iCT. INTERVENTIONS: Mailing educational material with recommendations on the appropriate use of LABA and a list of their patients with inappropriate prescriptions. MAIN MEASUREMENT: Appropriateness of LABA prescriptions as indicated in the Product Summary Characteristics. Patient age, sex, type of LABA and diagnoses were analysed. SOURCES: An information system for billing computerized prescriptions and medical history. RESULTS: Before intervention, prescriptions were inappropriate in 70.3% of patients, and 51.8% received LABA without iCT for unapproved conditions. A diagnosis associated with a respiratory condition was not recorded in the Computerised Medical Records of 18.5% of the patients. After intervention, the percentage of inappropriate prescriptions in the sample dropped to 4.5%, mainly due to a review of the treatment (LABA cessation or iCT addition). CONCLUSIONS: There is a high level of inappropriate use of LABA in Primary Health Care. Mailing educational materials combined with the list of patients with an inappropriate LABA prescription to general practitioners seems to be an effective strategy to improve quality prescribing in respiratory pathologies.

Linfangioma quístico sin otras anomalías asociadas / Cystic lymphangioma without associated anomalies

El higroma, o linfangioma quístico, se debe a una anomalía del sistema linfático producida por la obstrucción del drenaje de los sacos linfáticos cervicales al sistema venoso yugular. Habitualmente se localiza en la región cervical posterior o posterolateral y contiene múltiples tabiques. Entre el 20 y el 40% de los casos se asocia a normalidad cromosómica; el resto de los casos se asocia a diversas aneuplodías o malformaciones. El diagnóstico diferencial incluye edema nucal, meningocele, encefalocele, teratoma cervical, seudomembranas, hemangioma y quiste placentario subcorial.Su incidencia es de uno cada 1.775 a 6.000 nacidos vivos. La tasa de aneuploidía asociada al linfangioma quístico diagnosticado prenatalmente es del 45 al 60% (principalmente síndrome de Turner y síndrome de Down). También se ha observado asociación a otros síndromes polimalformativos. El resultado fetal es incierto y varía según los estudios revisados.A continuación se presenta el caso de un linfangioma quístico inusual por varios motivos: su gran tamaño, la ausencia de otras anomalías morfológicas y de aneuploidías, la joven edad de la madre y el desarrollo morfológico posnatal normal (AU)

Hygroma or cystic lymphangioma is due to an obstruction of jugular lymph sac drainage to the jugular venous system. The most common localization is the posterolateral neck region. These lesions are usually multiseptated. Between 20% and 40% of affected individuals have a normal karyotype and the remainder show diverse aneuploidies and/or malformations. The differential diagnosis includes nuchal edema, meningocele, encephalocele, cervical teratoma, pseudomembranes, hemangioma and subchorial placental cyst.The incidence of cystic lymphangioma has been reported to be 1/6,000–1,775 live-newborns. The rate of aneuploidy associated with prenatally diagnosed cases are between 45% and 60% (mainly Turner and Down syndromes). Some cases are associated with other polymalformation syndromes. Fetal outcome is uncertain and differs among studies.We present the case of a fetal cystic lymphangioma that is unusual for several reasons: its huge size, the absence of any other morphological abnormalities and aneuploidies, the young age of the mother, and the normal morphological postnatal growth (AU)

Manejo del hiperaldosteronismo primario en la provincia de Cáceres. Experiencia de 20 años / Management of primary hiperaldosteronism in the Cáceres province. Twenty-year experience

El hiperaldosteronismo primario (HA1.º) es una forma secundaria de hipertensión arterial (HTA) de fácil diagnóstico, provocado por la secreción inadecuada de aldosterona por la corteza suprarrenal. Con el objeto de establecer las principales características clínicas y bioquímicas de estos pacientes revisamos la base de datos de los últimos 20 años de la consulta monográfica de HTA del Servicio de Nefrología del Hospital San Pedro de Alcántara. De los 937 pacientes con HTA de origen no renal, 16 fueron diagnosticados de HA1.º (1,7 por ciento). No encontramos diferencias en cuanto al sexo. La media de edad fue de 45,8 +/- 9,28 años. Sólo 10 de los 16 presentaban clínica sugerente de HA1.º La tensión arterial (TA) media en la primera consulta fue de 161 +/- 19/101 +/- 13 mmHg. La repercusión orgánica en el momento del diagnóstico era grado II en el 50 por ciento de los casos y grado I en el 50 por ciento restante. Se constató hipopotasemia en 10 pacientes; los 6 restantes presentaban niveles de potasio normales. En todos encontramos niveles elevados de aldosterona basal; en 2 casos la renina no se encontraba suprimida. La gammagrafía con yodo-colesterol permitió localizar la lesión en 13 de los 16 pacientes; la tomografía axial computarizada y la resonancia magnética identificaron 2 casos confirmados por el test postural y la respuesta quirúrgica; en un caso no pudo establecerse la localización. Se diagnosticaron 8 adenomas y 7 hiperplasias bilaterales. Se intervinieron quirúrgicamente 5 de los adenomas, permaneciendo 3 pacientes normotensos son tratamiento y dos con buena respuesta ( cifras de TA normales con dosis bajas de espironolactona). Las hiperplasias, los adenomas no intervenidos y el caso no localizado presentan cifras de TA normales con dosis bajas de espironolactona (AU)