Impacto de un modelo estandarizado para la declaración y análisis de incidentes en la mejora de un servicio de Urgencias pediátrico / Impact on the improvement of paediatric emergency services using a standardised model for the declaration and analysis of incidents

INTRODUCCIÓN: El objetivo del trabajo es analizar los cambios en la declaración de incidentes tras haber implantado un nuevo sistema de declaración y exponer las medidas aplicadas gracias a las declaraciones realizadas. PACIENTES Y MÉTODOS: En el 2012 se realizó una recogida de los incidentes declarados de forma prospectiva entre 2007 y 2011. En mayo del 2012 se realizó un cambio de modelo para aumentar las declaraciones, analizar sus causas y mejorar el retorno de información al resto del equipo. Se nombraron referentes de seguridad en cada servicio, se realizaron sesiones informativas y de difusión, y se implantó un nuevo sistema de declaración de incidentes. Con el nuevo modelo se inició un estudio prospectivo de las declaraciones durante un año y se compararon los resultados con ambos modelos. RESULTADOS: En todo el 2011 se declararon 19 incidentes en Urgencias y del 1 de junio de 2012 al 31 de mayo del 2013, 106 incidentes (5,6 veces más). Los incidentes declarados fueron de medicación (57%), identificación (26%) y procedimientos (7%). Las causas más frecuentes de estos fueron individuales del profesional (70,7%), falta de formación (22,6%) y condiciones de trabajo (15,1%). Medidas que se han aplicado a raíz de estos incidentes son el checklist quirúrgico, las monodosis de salbutamol y tablas por peso de fármacos de reanimación cardiopulmonar. CONCLUSIONES: El nuevo modelo de declaración de incidentes ha potenciado las declaraciones, ha permitido implantar mejoras y medidas preventivas, aumentando todo esto el clima de seguridad en el servicio de Urgencias

INTRODUCTION: The aim of this study is to analyse changes in the incidents reported after the implementation of a new model, and study its results on patient safety. PATIENTS AND METHODS: In 2012 an observational study with prospective collection of incidents reported between 2007 and 2011 was conducted. In May 2012 a model change was made in order to increase the number of reports, analyse their causes, and improve the feedback to the service. Professional safety representatives were assigned to every department, information and diffusion sessions were held, and a new incident reporting system was implemented. With the new model, a new observational study with prospective collection of the reports during one year was initiated, and the results compared between models. RESULTS: In 2011, only 19 incidents were reported in the Emergency Department, and between June 1, 2012 to June 1, 2013, 106 incidents (5.6 times more). The incidents reported were medication incidents (57%), identification (26%), and procedures (7%). The most frequent causes were human (70.7%), lack of training (22.6%), and working conditions (15.1%). Some measures were implemented as a result of these incidents: a surgical checklist, unit doses of salbutamol, tables of weight-standardised doses of drugs for cardiopulmonary resuscitation. CONCLUSIONS: The new model of reporting incidents has enhanced the reports and has allowed improvements and the implementation of preventive measures, increasing the patient safety in the Emergency Department

Dactilitis, debut precoz de drepanocitosis y predictor de mal pronóstico / Dactylitis, early onset of drepanocytosis and a predictor of a poor prognosis

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[Impact on the improvement of paediatric emergency services using a standardised model for the declaration and analysis of incidents]. / Impacto de un modelo estandarizado para la declaración y análisis de incidentes en la mejora de un servicio de Urgencias pediátrico.

INTRODUCTION: The aim of this study is to analyse changes in the incidents reported after the implementation of a new model, and study its results on patient safety. PATIENTS AND METHODS: In 2012 an observational study with prospective collection of incidents reported between 2007 and 2011 was conducted. In May 2012 a model change was made in order to increase the number of reports, analyse their causes, and improve the feedback to the service. Professional safety representatives were assigned to every department, information and diffusion sessions were held, and a new incident reporting system was implemented. With the new model, a new observational study with prospective collection of the reports during one year was initiated, and the results compared between models. RESULTS: In 2011, only 19 incidents were reported in the Emergency Department, and between June 1, 2012 to June 1, 2013, 106 incidents (5.6 times more). The incidents reported were medication incidents (57%), identification (26%), and procedures (7%). The most frequent causes were human (70.7%), lack of training (22.6%), and working conditions (15.1%). Some measures were implemented as a result of these incidents: a surgical checklist, unit doses of salbutamol, tables of weight-standardised doses of drugs for cardiopulmonary resuscitation. CONCLUSIONS: The new model of reporting incidents has enhanced the reports and has allowed improvements and the implementation of preventive measures, increasing the patient safety in the Emergency Department.

Impacto de un cambio de programa informático en los errores de prescripción farmacológica en urgencias / Impact of a change of computer software on prescription drug errors in an emergency department

Introducción: Un cambio de programa informático es un factor de riesgo de errores de prescripción farmacológica. Nuestro objetivo fue evaluar la eficacia de medidas preventivas para evitar estos errores en nuestro centro. Material y métodos: En el año 2007 (período 1), ante un futuro cambio de programa informático, se realizó un estudio de los errores de tratamiento y se diseñó un plan de prevención. Se clasificaron los errores según el tipo (indicación, dosis, vía de administración), la gravedad y los factores asociados a errores (nivel de urgencia, edad del paciente, experiencia del facultativo, día de la semana y hora del día). Tras la implantación del nuevo programa (año 2009) (período 2) se reevaluaron los mismos parámetros y se compararon con el período previo. Se realizó una revisión retrospectiva de todos los informes donde constaba algún tratamiento administrado en urgencias la misma semana y mes de ambos períodos. Resultados: En el período 1 se realizaron 615 prescripciones con errores en 92 (15%) y en el período 2, 445 con 51 (11,5%) errores, sin diferencias significativas entre ambos. Se observó una disminución significativa de errores de indicación inapropiada (8,1% período 1 vs 3,6% período 2; p=0,04) sin diferencias en los de dosis, vía de administración y gravedad del error. Se redujeron de forma significativa los errores en los facultativos de mayor experiencia y aumentaron en los rotantes externos (que no recibieron formación en el funcionamiento del nuevo programa). Conclusiones: El conocimiento de la situación previa y la aplicación de medidas preventivas permitieron que no aumentaran los errores con un nuevo programa informático(AU)

Introduction: Changing the computer software is a known risk factor of increased prescription drug errors. The aim of this study was to evaluate the effectiveness of preventive measures to prevent these errors at our centre. Material and methods: In 2007 (period 1), knowing that a change of computer software was coming, a study to determine the prescription drug errors was performed and an improvement plan was designed. Errors were classified as: type of error (indication, dosage, route of administration), severity and associated risk factors (emergency level, patient age, physician experience, day of week, time of day). Following the introduction of the new computer software (year 2009) (period 2), the same parameters were re-evaluated and compared with the previous period. All Paediatric Emergency Department (PED) reports, where some treatment was administered in the Emergency room in the same week and month for both periods, were reviewed. Results: A total of 615 prescriptions were written during period 1, of which 92 (15%) were classified as errors, and in period 2, 445 were written and 51 (11.5%) had errors, with no significant differences between both periods. There was a significant decrease in inappropriate indication errors (8.1% in period 1 vs 3.6% in period 2; P=.04), with no differences in dosage, route of administration and severity of errors. There was a significant error reduction in more experienced physicians, and an increase in errors by external rotation physicians (who were not skilled in the use of the new program). Conclusions: The knowledge of the previous situation and the use of preventive measures ensured that errors did not increase after a change of computer software(AU)

[Impact of a change of computer software on prescription drug errors in an emergency department]. / Impacto de un cambio de programa informático en los errores de prescripción farmacológica en urgencias.

INTRODUCTION: Changing the computer software is a known risk factor of increased prescription drug errors. The aim of this study was to evaluate the effectiveness of preventive measures to prevent these errors at our centre. MATERIAL AND METHODS: In 2007 (period 1), knowing that a change of computer software was coming, a study to determine the prescription drug errors was performed and an improvement plan was designed. Errors were classified as: type of error (indication, dosage, route of administration), severity and associated risk factors (emergency level, patient age, physician experience, day of week, time of day). Following the introduction of the new computer software (year 2009) (period 2), the same parameters were re-evaluated and compared with the previous period. All Paediatric Emergency Department (PED) reports, where some treatment was administered in the Emergency room in the same week and month for both periods, were reviewed. RESULTS: A total of 615 prescriptions were written during period 1, of which 92 (15%) were classified as errors, and in period 2, 445 were written and 51 (11.5%) had errors, with no significant differences between both periods. There was a significant decrease in inappropriate indication errors (8.1% in period 1 vs 3.6% in period 2; P=.04), with no differences in dosage, route of administration and severity of errors. There was a significant error reduction in more experienced physicians, and an increase in errors by external rotation physicians (who were not skilled in the use of the new program). CONCLUSIONS: The knowledge of the previous situation and the use of preventive measures ensured that errors did not increase after a change of computer software.

Resultados de una estrategia de prevención de errores de medicación en un servicio de urgencias pediátrico / Results of a program to prevent medication errors in a pediatric emergency department

Objetivos: Los errores de prescripción farmacológica son causa de una importante y prevenible morbimortalidad en niños. Nuestro objetivo fue valorar la reducción estos errores de medicación en un servicio de urgencias pediátrico tras aplicar estrategias de prevención. Método: Estudio observacional pre y postintervención. En noviembre de 2009 (periodo1) se revisaron los errores de prescripción a través de las historias informatizadas, que se clasificaron en: tipo (dosis, indicación, vía de administración), gravedad (leve, moderado o grave) y factores asociados (experiencia del facultativo, nivel de urgencia, día de la semana y hora del día). Durante el 2010 se realizaron sesiones con difusión de los errores detectados y se colgaron carteles informativos en urgencias. En noviembre de 2010 (periodo 2) se reevaluaron los mismos parámetros y se compararon los resultados. Resultados: Los fármacos con más errores fueron los broncodilatadores, los corticoides y los antiinflamatorios. En el periodo 1 se detectaron 49 errores de 445 prescripciones(11%) y en el periodo 2, 48 errores entre 557 prescripciones (8,6%), (p = NS). Disminuyeron los errores de dosis (7,4% vs 3,8%; p = 0,016), sin cambios significativos en los de indicación y vía de administración, ni en la gravedad de los errores. Se observó una reducción significativa del total de errores en los pacientes más urgentes (11,6% vs5,7%; p = 0,005) y por las noches (0-8 h) (16,2% vs 6,1%; p = 0,02).Conclusiones: Las medidas implantadas han permitido disminuir algunos tipos de errores de medicación pero es necesario mantener el seguimiento e insistir en estrategias de prevención (AU)

Background and objective: Drug prescription errors are a significant cause of preventable morbidity and mortality in children. Our aim was to assess whether the frequency of medication error decreased after a prevention program was implemented in a pediatric emergency department. Material and methods: Observational pre- and postintervention study. We identified errors made in November 2009(preintervention period) by reviewing patient records. Errors were classified by type (dose, indication, route of administration), level of seriousness (low, moderate, high), and associated factors (staff experience, seriousness of the emergency, day of the week, hour of the day). In 2010 sessions to provide information about the detected errors were held and informative posters were hung in the department. Errors were again identified in November 2010(postintervention period) and the results were compared. Results: Errors were made most often with bronchodilators, corticosteroids, and anti-inflammatory drugs. In the first period, out of 445 prescriptions made, 49 errors (11%) were detected; in the second period, 48 errors in 557prescriptions (8.6%) were detected. The difference was not significant. The rate of dosage error decreased significantly between the 2 periods (7.4% vs 3.8%, P=.016), but we saw no significant changes in incorrect indication, choice of route of administration, or seriousness. During the postintervention period, fewer errors were made in the most serious emergencies (11.6% vs 5.7%; P=.005) and between midnight and 8 a.m. (16.2% vs 6.1%; P=.02).Conclusions: The error prevention program allowed us to reduce some types of medication error but follow-up and continued insistence on vigilance is required (AU)

Características clínicas de la gripe A H1N1 2009: estudio multicéntrico / Clinical features of influenza A H1N1 2009: a multicentre study

Objetivo: Describir las características clínico-epidemiológicas de los niños diagnosticados de gripe A H1N1 2009 en urgencias de 4 hospitales. Material y métodos: Estudio prospectivo multicéntrico de julio a diciembre 2009. Se incluyó a los pacientes diagnosticados de gripe A H1N1 2009 por PCR en tiempo real en urgencias. La solicitud de la prueba se hizo según los protocolos establecidos en cada momento de la epidemia. Se recogieron datos epidemiológicos, clínicos, de laboratorio y evolutivos. Resultados: Se incluyeron 456 casos con una mediana de edad de 6,5 años (PC25-75 3-10,6).Presentaron factores de riesgo para complicaciones de la gripe 266 pacientes (59,4%); principalmente complicaciones pulmonares (47%), cardiovasculares (17%), neurológicos (14%) e inmunodeficiencias (11%). La clínica más frecuente fue fiebre (96%), tos (88%), rinorrea (72%), mialgias o astenia y dificultad respiratoria y, menos frecuentes, síntomas digestivos y neurológicos. Se solicitó radiografía de tórax a 224 pacientes (49%), presentando un 31% infiltrados lobares y un 15% intersticiales. Ciento cuarenta pacientes fueron hospitalizados (31%), necesitando el apoyo de la unidad de cuidados intensivos (mediana de estancia 4 y 3,5 días, respectivamente).Las complicaciones más frecuentes fueron neumonías y crisis de broncospasmo. Fallecieron3 pacientes (un paciente previamente sano por miocarditis y 2 con encefalopatía por fallo respiratorio). Otro caso de miocarditis se recuperó con secuelas. Conclusiones: El perfil del paciente con gripe A H1N1 2009 diagnosticada en urgencias fue el de un escolar, con factores de riesgo de complicaciones, que presentaba sintomatología respiratoria febril de corta evolución al que pudo darse de alta. Además de las complicaciones respiratorias habituales de la gripe, destacaron los casos de afectación miocárdica (AU)

Objective: To describe clinical and epidemiological features of influenza A H1N1 2009 diagnosed patients in the Emergency Department of 4 hospitals. Material and methods: Prospective multicentre study conducted from july to december 2009. The patients diagnosed by Real-Time PCR of influenza A H1N1 2009 in the emergency department were included. The test was requested according to the protocols established throughout the epidemic. Epidemiological, clinical, laboratory variables and outcomes were evaluated. Results: A total of 456 cases were included, with a median age of 6.5 years (PC25-75 3-10.6). There were risk factors of complications In 266 patients (59.4%) due to the influenza, mainly: respiratory (47%), cardiovascular (17%), neurological (14%) and immunosuppression (11%). The most frequent symptoms were fever (96%), (88%) cough, (72%) rhinorrhoea, muscle aches orasthenia and breathing difficulties and, less common, gastrointestinal and neurological symptoms. Chest X-ray was performed on 224 cases (49%), with lobar (31%) and interstitial (15%) infiltrates. One hundred and forty patients (31%) were hospitalised and 3.2% required Intensive Care Unit (median stay 4 and 3.5 days, respectively). The most frequent complications were pneumonias and bronchospasms. Three patients died (a previously healthy patient with myocarditis and 2 patients with encephalopathy due to respiratory failure). Another case of myocarditis recovered with sequelae. Conclusions: The profile of patient with influenza A 2009 diagnosed in the emergency department was a school child, with risk factors of complications, presenting with respiratory symptoms and fever over a short time, and who can be discharged. It is important to emphasise myocarditis, as well as the usual respiratory complications of influenza virus (AU)

[Clinical features of influenza A H1N1 2009: a multicentre study]. / Características clínicas de la gripe A H1N1 2009: estudio multicéntrico.

OBJECTIVE: To describe clinical and epidemiological features of influenza A H1N1 2009 diagnosed patients in the Emergency Department of 4 hospitals. MATERIAL AND METHODS: Prospective multicentre study conducted from july to december 2009. The patients diagnosed by Real-Time PCR of influenza A H1N1 2009 in the emergency department were included. The test was requested according to the protocols established throughout the epidemic. Epidemiological, clinical, laboratory variables and outcomes were evaluated. RESULTS: A total of 456 cases were included, with a median age of 6.5years (PC(25-75) 3-10.6). There were risk factors of complications In 266 patients (59.4%) due to the influenza, mainly: respiratory (47%), cardiovascular (17%), neurological (14%) and immunosuppression (11%). The most frequent symptoms were fever (96%), (88%) cough, (72%) rhinorrhoea, muscle aches or asthenia and breathing difficulties and, less common, gastrointestinal and neurological symptoms. Chest X-ray was performed on 224 cases (49%), with lobar (31%) and interstitial (15%) infiltrates. One hundred and forty patients (31%) were hospitalised and 3.2% required Intensive Care Unit (median stay 4 and 3.5days, respectively). The most frequent complications were pneumonias and bronchospasms. Three patients died (a previously healthy patient with myocarditis and 2 patients with encephalopathy due to respiratory failure). Another case of myocarditis recovered with sequelae. CONCLUSIONS: The profile of patient with influenza A 2009 diagnosed in the emergency department was a school child, with risk factors of complications, presenting with respiratory symptoms and fever over a short time, and who can be discharged. It is important to emphasise myocarditis, as well as the usual respiratory complications of influenza virus.

Vaginitis recurrente y peritonitis por Streptococcus pneumoniae en niña prepuberal / Streptococcus pneumoniae-induced recurrent vaginitis and peritonitis in a prepubertal child

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Fracturas ocultas en lactantes: a propósito de 2 casos / Occult fractures in infants: a report of two cases

La fractura de Toddler es una fractura espiroidea de tibia, no desplazada, que se produce en niños pequeños secundariamente a un traumatismo, muchas veces inadvertido. Está causada por fuerzas de torsióncuando el niño gira, cae en su cuna y/o está aprendiendo a caminar y cae con frecuencia. La clínica suele ser inespecífica y, con frecuencia, no es visible en las radiografías convencionales, a veces sólo es demostrable en una de las proyecciones, por lo que a menudo se diagnostica tardíamente, al aparecer el callo de fractura. Suele confundirse con otras enfermedades que causan cojera en la infancia, como la sinovitis transitoria de cadera o las infecciones osteoarticulares. En ocasiones, es ssecundaria a un maltrato infantil. A continuación presentamos 2 casos que ilustran la dificultad diagnóstica de este tipo de fracturas en un servicio de urgencias. El primero se orientó como una sinovitis transitoria de cadera y el segundo como una osteomielitis aguda, y en ambos se realizó el diagnóstico de forma tardía

Toddler´s fracture is a nondisplaced spiral fracture of the tibia in a small child. It is due to a twisting force, and often goes undetected. The etiology is a low energy trauma. Examination may detect a pain response at the fracture site, and conventional radiographs are usually normal. Thus, these fractures may be diagnosed some weeks after injury because of periosteal new bone formation requiring the exclusion of other causes of limping in childhood (transient hip synovitis, septic arthritis, tumors). The possibility of physical abuse should be considered. We present two cases observed in our emergency department that illustrate the diagnostic difficulties posed by fractures of this type. One was initially diagnosed as transient synovitis and the other as acute osteomyelitis, until we discovered, some weeks later, that we were dealing with occult fractures

Linfangioma abdominal infectado por Salmonella enteritidis / Abdominal lymphangioma infected by Salmonella enteritidis

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