Factors affecting mortality after coronary bypass surgery: a scoping review.

OBJECTIVES: Previous research reports numerous factors of post-operative mortality in patients undergoing isolated coronary artery bypass graft surgery. However, this evidence has not been mapped to the conceptual framework of care improvement. Without such mapping, interventions designed to improve care quality remain unfounded. METHODS: We identified reported factors of in-hospital mortality post isolated coronary artery bypass graft surgery in adults over the age of 19, published in English between January 1, 2000 and December 31, 2019, indexed in PubMed, CINAHL, and EMBASE. We grouped factors and their underlying mechanism for association with in-hospital mortality according to the augmented Donabedian framework for quality of care. RESULTS: We selected 52 factors reported in 83 articles and mapped them by case-mix, structure, process, and intermediary outcomes. The most reported factors were related to case-mix (characteristics of patients, their disease, and their preoperative health status) (37 articles, 27 factors). Factors related to care processes (27 articles, 12 factors) and structures (11 articles, 6 factors) were reported less frequently; most proposed mechanisms for their mortality effects. CONCLUSIONS: Few papers reported on factors of in-hospital mortality related to structures and processes of care, where intervention for care quality improvement is possible. Therefore, there is limited evidence to support quality improvement efforts that will reduce variation in mortality after coronary artery bypass graft surgery.

Incidence of Suspected Serious Adverse Drug Reactions in Corona Virus Disease-19 Patients Detected by a Pharmacovigilance Program by Laboratory Signals in a Tertiary Hospital in Spain: Cautionary Data.

BACKGROUND: From March to April 2020, Spain was the center of the SARS-CoV-2 pandemic, particularly Madrid with approximately 30% of the cases in Spain. The aim of this study is to report the suspected serious adverse drug reactions (SADRs) in COVID-19 patients vs. non-COVID-19 patients detected by the prospective pharmacovigilance program based on automatic laboratory signals (ALSs) in the hospital (PPLSH) during that period. We also compared the results with the suspected SADRs detected during the same period for 2019. METHODS: All ALSs that reflected potential SADRs including neutropenia, pancytopenia, thrombocytopenia, anemia, eosinophilia, leukocytes in cerebrospinal fluid, hepatitis, pancreatitis, acute kidney injury, rhabdomyolysis, and hyponatremia were prospectively monitored in hospitalized patients during the study periods. We analyzed the incidence and the distribution of causative drugs for the COVID-19 patients. RESULTS: The incidence rate of SADRs detected in the COVID-19 patients was 760.63 (95% CI 707.89-816.01) per 10,000 patients, 4.75-fold higher than the SADR rate for non-COVID-19 patients (160.15 per 10,000 patients, 95% CI 137.09-186.80), and 5.84-fold higher than the SADR rate detected for the same period in 2019 (130.19 per 10,000 patients, 95% CI 109.53-154.36). The most frequently related drugs were tocilizumab (59.84%), dexketoprofen (13.93%), azithromycin (8.43%), lopinavir-ritonavir (7.35%), dexamethasone (7.62%), and chloroquine/hydroxychloroquine (6.91%). CONCLUSIONS: The incidence rate of SADRs detected by the PPSLH in patients with COVID-19 was 4.75-fold higher than that of the non-COVID-19 patients. Caution is recommended when using medications for COVID-19 patients, especially drugs that are hepatotoxic, myotoxic, and those that induce thromboembolic events.

E-learning on risk management. An opportunity for sharing knowledge and experiences in patient safety.

QUALITY PROBLEM: E-learning methodology is a good alternative to more traditional methods when economical restrictions and geographical dispersion are important. However, there is still little knowledge about its utility in the development of patient safety (PS) improvement projects. INITIAL ASSESSMENT: Evaluation of the acceptability and utility of an e-learning risk management (RM) course for healthcare professionals to develop PS improvement projects in different clinical settings. CHOICE OF SOLUTION: E-course offered, in Spanish and English, to facilitate the design of PS improvement projects using RM tools under the continuous support of PS experts. IMPLEMENTATION: The evaluation of the course was based on the reaction, learning and healthcare professional behavior. A free online database was created to disseminate and share the projects developed during the course. EVALUATION: A total of 1426 professionals have completed the course (84.2%), of which 86.7% (1236) were from Spain, 8.3% (118) from Latin America and 5% (72) from other European and Eastern Mediterranean countries. More than 80% of the students were very satisfied with the e-course and 98% would recommend it to their colleagues. Learning and developing improvement projects through teamwork was highlighted as a very positive aspect. A total of 70.3% of the 387 PSIP were developed in hospitals. The most frequent topic was medication. LESSON LEARNED: Team learning based on real cases was one of the most positive aspects of the e-course. The improvement projects developed are transferable examples of good practices that facilitate the application of RM tools in different clinical settings.

Effectiveness and limitations of an incident-reporting system analyzed by local clinical safety leaders in a tertiary hospital: Prospective evaluation through real-time observations of patient safety incidents.

The effectiveness of a hospital incident-reporting system (IRS) on improve patient safety is unclear. This study objective was to assess which implemented improvement actions after the analysis of the incidents reported were effective in reduce near-misses or adverse events.Patient safety incidents (PSIs), near misses and adverse events, notified to the IRS were analyzed by local clinical safety leaders (CSLs) who propose and implement improvement actions. The local CSLs received training workshops in patient safety and analysis tools. Following the notification of a PSI in the IRS, prospective real-time observations with external staff were planned to record and rated the frequency of that PSI. This methodology was repeated after the implementation of the improvement actions.Ultimately, 1983 PSIs were identified. Surgery theaters, emergency departments, intensive care units, and general adult care units comprised 82% of all PSIs. The PSI rate increased from 0.39 to 3.4 per 1000 stays in 42 months. A significant correlation was found between the reporting rate per month and the number of workshop-trained local CSLs (Spearman coefficient = 0.874; P = .003). A total of 24,836 real-time observations showed a statistically significant reduction in PSIs observed in 63.15% (categories: medication P = .044; communication P = .037; technology P = .009) of the implemented improvements actions, but not in the organization category (P = .094). In the multivariate analyses, the following factors were associated with the reduction in near misses or adverse events after the implementation of the improvement actions: "adverse event" type of PSI (odds ratio [OR], 3.67; 95% confidence interval [CI], 1.93-5.74), "disussion group" type of analysis (OR, 2.45; 95% CI, 1.52-3.76), and root cause type of analysis (OR, 2.32; 95% CI: 1.17-3.90).The implementation of a hospital IRS, together with the systematization of the method and analysis of PSIs by workshop-trained local CSLs led to an important reduction in the frequency of PSIs.

Patient and system factors of time to surgery after hip fracture: a scoping review.

OBJECTIVES: It is disputed whether the time a patient waits for surgery after hip fracture increases the risk of in-hospital death. This uncertainty matters as access to surgery following hip fracture may be underprioritised due to a lack of definitive evidence. Uncertainty in the available evidence may be due to differences in characteristics of patients, their injury and their care. We summarised the literature on patients and system factors associated with time to surgery, and collated proposed mechanisms for the associations. METHODS: We used the framework developed by Arksey and O'Malley and Levac et al for synthesis of factors and mechanisms of time to surgery after hip fracture in adults aged >50 years, published in English, between 1 January 2000 and 28 February 2017, and indexed in MEDLINE, EMBASE, CINAHL or Ageline. Proposed mechanisms for reported associations were extracted from discussion sections. RESULTS: We summarised evidence from 26 articles that reported on 24 patient and system factors of time to surgery post hip fracture. In total, 16 factors were reported by only one article. For 16 factors we found proposed mechanisms for their association with time to surgery which included surgical readiness, available resources, prioritisation and out-of-hours admission. CONCLUSIONS: We identified patient and system factors associated with time to surgery after hip fracture. This new knowledge will inform evaluation of the putative timing-death association. Future interventions should be designed to influence factors with modifiable mechanisms for delay.

Prescripción potencialmente inapropiada en mayores de 65 años en un centro de salud de atención primaria / Potentially inappropriate prescribing in patients over 65 years-old in a primary care health centre

OBJETIVO: Identificar las prescripciones potencialmente inapropiadas (PPI) y omisiones de prescripción (OP) mediante los criterios STOPP/START y factores asociados en pacientes ≥ 65 años en un centro de salud de atención primaria. DISEÑO: Estudio descriptivo-transversal. Emplazamiento: Centro de Salud Monóvar, atención primaria. Período de estudio: 6 meses. Participantes: Doscientos cuarenta y siete sujetos identificados mediante aleatorización simple. CRITERIOS DE INCLUSIÓN: individuos de ≥ 65 años que acudieron a la consulta médica ≥ 2 veces en el período de estudio. Exclusión: situación terminal y pertenecientes a residencias. MÉTODOS: Recogida de datos a través de historias clínicas electrónicas. Se evaluaron: criterios STOPP/START, edad, sexo, comorbilidad y número de fármacos crónicos. Variables principales: PPI y OP identificadas por los criterios STOPP y START, respectivamente. RESULTADOS: Se identificaron 81 pacientes (32,8%) con PPI; la más frecuente correspondió a benzodiacepinas de vida media larga en 17 (6,9%). Se encontraron 73 (29,6%) con OP; la más frecuente fue la ausencia de estatinas en pacientes con diabetes mellitus, y uno o más factores mayores de riesgo cardiovascular en 21 (8,5%). Asociación de PPI con polimedicación ajustado por edad y sexo (OR: 2,02; IC 95%: 1,15-3,53; p = 0,014) y asociación de OP con polimedicación ajustado por edad y sexo (OR: 2,37; IC 95%: 1,32-4,24; p = 0,004). CONCLUSIONES: La prescripción inapropiada en mayores es frecuente y está relacionada con el uso de benzodiacepinas de vida media larga. Existen diabéticos con factores de riesgo cardiovascular en los que se omiten las estatinas. La polimedicación juega un papel importante en las PPI y OP

OBJECTIVE: To identify potentially inappropriate prescriptions (PPI) and prescribing omissions(OP) by means of the STOPP/START criteria, as well as associated factors in≥65 year old patients in a Primary Care setting in Spain. Study DESIGN: A cross-sectional, descriptive study. Setting: Centro de Salud Monóvar, Primary Health Care. Study period: 6 months. Patients Random sample: 247 patients. Eligibility criteria:≥65 years patients who attended an urban Primary Care clinic 2 or more times were studied. Terminally ill and nursing home residents were excluded. METHODS: Data were collected from electronic clinical records. STOPP and START criteria were evaluated in each clinical record, including age, sex, co-morbidity, number of chronic prescriptions. Main outcomes: PPI and OP identified by STOPP and START criteria, respectively. RESULTS: A total of 81 patients (32.8%) had PPI, with the most common being the long-term use of long-acting benzodiazepines in 17 (6.9%). OP was found in 73 (29.6%) patients, with the most common being the omission of statins in patients diagnosed with diabetes mellitus and/or one or more major cardiovascular risk factors in 21 (8.5%). After adjustment by gender and age, correlations were found between PPI and multiple medication (OR: 2.02; 95% CI: 1.15-3.53;P = .014), and OP and polypharmacy (OR: 2.37; 95% CI: 1.32-4.24; P = 0.004). CONCLUSIONS: Inappropriate prescribing in older people is frequent, and is mainly associated with long-acting benzodiazepines. There are diabetic patients who do not have statins prescribed. Multiple medication is associated with PPI and OP

[Potentially inappropriate prescribing in patients over 65 years-old in a primary care health centre]. / Prescripción potencialmente inapropiada en mayores de 65 años en un centro de salud de atención primaria.

OBJECTIVE: To identify potentially inappropriate prescriptions (PPI) and prescribing omissions (OP) by means of the STOPP/START criteria, as well as associated factors in ≥65year old patients in a Primary Care setting in Spain. STUDY DESIGN: A cross-sectional, descriptive study. SETTING: Centro de Salud Monóvar, Primary Health Care. STUDY PERIOD: 6months. PATIENTS RANDOM SAMPLE: 247patients. ELIGIBILITY CRITERIA: ≥65years patients who attended an urban Primary Care clinic 2 or more times were studied. Terminally ill and nursing home residents were excluded. METHODS: Data were collected from electronic clinical records. STOPP and START criteria were evaluated in each clinical record, including age, sex, co-morbidity, number of chronic prescriptions. MAIN OUTCOMES: PPI and OP identified by STOPP and START criteria, respectively. RESULTS: A total of 81 patients (32.8%) had PPI, with the most common being the long-term use of long-acting benzodiazepines in 17 (6.9%). OP was found in 73 (29.6%) patients, with the most common being the omission of statins in patients diagnosed with diabetes mellitus and/or one or more major cardiovascular risk factors in 21 (8.5%). After adjustment by gender and age, correlations were found between PPI and multiple medication (OR: 2.02; 95%CI: 1.15-3.53; P=.014), and OP and polypharmacy (OR: 2.37; 95%CI: 1.32-4.24; P=0.004). CONCLUSIONS: Inappropriate prescribing in older people is frequent, and is mainly associated with long-acting benzodiazepines. There are diabetic patients who do not have statins prescribed. Multiple medication is associated with PPI and OP.