Cultura de segurança em unidades de terapia intensiva na perspectiva da equipe multiprofissional: Estudo multicêntrico / Cultura de seguridad en unidades de terapia intensiva en la perspectiva del equipo multiprofesional: Estudio multicéntrico / Safety Culture in intensive care units from multiprofessional team perspective: A multicenter study

Resumo Introdução: A Cultura de Segurança do Paciente é considerada um importante componente estrutural dos serviços, que favorece a implantação de práticas seguras e a diminuição da ocorrência de eventos adversos. Objetivo: Identificar os fatores associados à cultura de segurança do paciente nas unidades de terapia intensiva adulto em hospitais de grande porte da região Sudeste do Brasil. Método: Estudo transversal do tipo survey e multicêntrico. Participaram 168 profissionais de saúde de quatro unidades (A, B, C e D) de terapia intensiva adulto. Foi utilizado o questionário "Hospital Survey on Patient Safety Culture". Considerou-se como variável dependente o nível de cultura de segurança do paciente e variáveis independentes aspectos sociodemográficos e laborais. Foram usadas estatísticas descritivas e para a análise dos fatores associados foi elaborado um modelo de regressão logística múltipla. Resultados: Identificou-se associação entre tipo de hospital com onze dimensões da cultura de segurança, quanto à função a categoria profissional médico, técnico de enfermagem e enfermeiro foram relacionadas com três dimensões; o gênero com duas dimensões e tempo de atuação no setor com uma dimensão. Conclusão: Evidenciou-se que o tipo de hospital, categoria profissional, tempo de atuação no setor e gênero foram associados às dimensões de cultura de segurança do paciente.

Resumen Introducción: La cultura de seguridad del paciente se considera un componente estructural importante de los servicios, que favorece la aplicación de prácticas seguras y la reducción de la aparición de acontecimientos adversos. Objetivo: Identificar los factores asociados a la cultura de seguridad del paciente en unidades de terapia intensiva adulto en hospitales de la región Sudeste del Brasil. Metodología: Estudio transversal de tipo encuesta y multicéntrico. Participaron 168 profesionales de salud de cuatro unidades (A, B, C y D) de terapia intensiva adulto. Se utilizó el cuestionario "Hospital Survey on Patient Safety Culture". Se consideró como variable dependiente el nivel de cultura de seguridad del paciente y variables independientes los aspectos sociodemográficos y laborales. Fueron usadas estadísticas descriptivas y, para analizar los factores asociados, fue elaborado un modelo de regresión logística múltiple. Resultados: Se identificó asociación entre tipo de hospital con once dimensiones de cultura de seguridad del paciente. En relación a la función, personal médico, técnicos de enfermería y personal de enfermería fueron asociados con tres dimensiones, el género con dos dimensiones y tiempo de actuación con una dimensión en el modelo de regresión. Conclusión: Se evidenció que el tipo de hospital, función, tiempo de actuación en el sector y género fueron asociados a las dimensiones de la cultura de seguridad del paciente.

Abstract Introduction: Patient safety culture is considered an important structural component of the services, which promotes the implementation of safe practices and the reduction of adverse events. Objective: To identify the factors associated with patient safety culture in adult intensive care units in large hospitals in Belo Horizonte. Method: Cross-sectional survey and multicenter study. A total of 168 health professionals from four units (A, B, C and D) of adult intensive care participated. The questionnaire "Hospital Survey on Patient Safety Culture" was used. The patient's level of safety culture was considered as a dependent variable, and sociodemographic and labor aspects were the independent variables. Descriptive statistics were used and a multiple logistic regression model was developed to analyze the associated factors. Results: An association was identified between the type of hospital and eleven dimensions of the safety culture. In terms of function, the doctors, nursing technicians, and nurse were related to three dimensions; gender with two dimensions, and time working in the sector with one dimension. Conclusion: It was evidenced that the type of hospital, function, time working in the sector, and gender were associated with the dimensions of patient safety culture.

Caring to care: Nurturing ICU healthcare professionals' wellbeing for enhanced patient safety.

Healthcare professionals working in the Intensive Care Unit (ICU) care for patients suffering from a critical illness and their relatives. Working within a team of people with different personalities, competencies, and specialties, with constraints and demands might contribute to a working environment that is prone to conflicts and disagreements. This highlights that the ICU is a stressful place that can threaten healthcare professionals' wellbeing. This article aims to address the concept of wellbeing by describing how the stressful ICU work-environment threatens the wellbeing of health professionals and discussing how this situation jeopardizes patient safety. To promote wellbeing, it is imperative to explore actionable interventions such as improve communication skills, educational sessions on stress management, or mindfulness. Promoting ICU healthcare professionals' wellbeing through evidence-based strategies will not only increase their personal resilience but might contribute to a safer and more efficient patient care.

How a single perioperative delirium case can make the difference.

This report describes how postoperative delirium in an elderly man during COVID-19 pandemic led to a serious event involving a central venous catheter. Delirium is a common cause of perioperative morbidity and mortality, and is characterised by an alteration in consciousness and perception and a reduced ability to focus, sustain or shift attention. The event was analysed by a multidisciplinary committee which developed a risk stratification delirium protocol in order to prevent similar events in the future.

[Ethics of care: Assessment of the ethical issues in the protocols or consensuses on mechanical restraint in force in Spain]. / Ética de los cuidados: valoración de los contenidos éticos en los protocolos o consensos de contención mecánica vigentes en España.

INTRODUCTION: Mechanical restraints are widely used in health care practice, despite the numerous ethical conflicts they raise. The aim of this study is to evaluate the ethical considerations contemplated in the current protocols on mechanical restraint in Spain. METHOD: Systematic review in PubMed, WOS and Scopus, Google and Google Scholar. An ad hoc list of 30 items was used to evaluate the ethical content of the protocols. The quality of guidelines was assessed with AGREE II. RESULTS: The need for informed consent (IC) is reflected in 72% of the documents, the IC model sheet is included in only 41% of them, the rest of the analyzed characteristics on IC are fulfilled in percentages between 6% (the document includes the need to reevaluate the indication for IC) and 31% (the document contemplates to whom it should be requested). More than 20 ethical contents are reflected in 31% of them and less than 10 in 19% of the guidelines. The quality of the guides, according to AGREE II, ranged from 27 to 116 points (maximum possible 161), with a mean score of 68.7. Only 9% of the documents were classified as high quality. Finally, the correlation between ethical content and quality measured with AGREE II was 0.75. CONCLUSIONS: The variability of ethical contents in guidelines on mechanical restraints is very high. The ethical requirements to be included in protocols, consensus or Clinical Practice Guidelines should be defined.

CLINICAL PROTOCOLS ADOPTED BY NURSES IN THE EXTRAVASATION OF ANTINEOPLASTIC DRUGS: AN INTEGRATIVE REVIEW / PROTOCOLOS CLÍNICOS ADOPTADOS POR ENFERMERÍA EN LA EXTRAVASACIÓN DE FÁRMACOS ANTINEOPLÁSICOS: UNA REVISIÓN INTEGRADORA / PROTOCOLOS CLÍNICOS ADOTADOS PELOS ENFERMEIROS NO EXTRAVASAMENTO DE ANTINEOPLÁSICOS: UMA REVISÃO INTEGRATIVA

Objective: To identify the patient safety measures and clinical protocols adopted by nurses in the case of antineoplastic extravasation. Methodology: The research approach was based on an integrative literature review that used the PICo strategy to structure the research question. Bibliographic surveys were carried out using the MEDLINE, Lilacs, BDENF, SciELO and PubMed databases using the following terms according to DeCS: "Clinical Protocols", " Extravasation of Therapeutic and Diagnostic Materials", "Oncology Nursing", "Patient Safety", "Antineoplastics". After applying the inclusion and exclusion criteria, 25 articles were selected, read in full, classified and organized according to the theme, and critically analyzed. Results: From the analysis of the studies, it was possible to delimit the main actions and knowledge of nurses in the management and guarantee of patient safety in the face of antineoplastic extravasation, as well as promising new managements in the prevention and treatment of this aggravation. Conclusion: Nurses' knowledge of specific measures for antineoplastic drug leakage is incipient, and there is a clear need for research to minimize the gaps in innovative knowledge in nursing practice with the aim of preventing extravasation.

Objetivo: Identificar las medidas de seguridad del paciente y los protocolos clínicos adoptados por el personal de enfermería en el caso de extravasación de antineoplásicos. Metodología: El abordaje de la investigación se basó en una revisión bibliográfica integradora que utilizó la estrategia PICo para estructurar la pregunta de investigación. Las pesquisas bibliográficas fueron realizadas en las bases de datos MEDLINE, Lilacs, BDENF, SciELO y PubMed, utilizando los siguientes términos de acuerdo con el DeCS: "Protocolos clínicos", " Extravasación de material terapéutico y de diagnóstico", "Enfermería oncológica", "Seguridad del paciente", "Antineoplásicos". Tras aplicar los criterios de inclusión y exclusión, se seleccionaron 25 artículos, que fueron leídos en su totalidad, clasificados y organizados según el tema, y analizados críticamente. Resultados: A partir del análisis de los estudios, fue posible delinear las principales acciones y conocimientos de las enfermeras en el manejo y garantía de la seguridad del paciente ante la extravasación de antineoplásicos, así como nuevos manejos promisorios en la prevención y tratamiento de este agravamiento. Conclusión: El conocimiento de las enfermeras sobre las medidas específicas para la fuga de fármacos antineoplásicos es incipiente, existiendo una clara necesidad de investigación para minimizar las lagunas de conocimiento innovador en la práctica enfermera con el objetivo de prevenir la extravasación.

Objetivo: Identificar quais são as medidas de segurança do paciente e protocolos clínicos adotados pelos enfermeiros no extravasamento de antineoplásicos. Metodologia: A abordagem da pesquisa se deu a partir de uma revisão integrativa da literatura que se utilizou da estratégia PICo para estruturar a questão de pesquisa. Foram realizados levantamentos bibliográficos utilizando as bases de dados MEDLINE, Lilacs, BDENF, SciELO e PubMed utilizando os termos segundo o DeCS: "Protocolos Clínicos", "Extravasamento de Materiais Terapêuticos e Diagnósticos", "Enfermagem Oncológica", "Segurança do paciente", "Antineoplásicos". Após a aplicação dos critérios de inclusão e exclusão, foram selecionados 25 artigos lidos na íntegra, classificados e organizados conforme a temática, e analisados criticamente. Resultados: A partir da análise dos estudos, foi possível delimitar as principais ações e conhecimentos dos enfermeiros no manejo e garantia da segurança do paciente diante do extravasamento de antineoplásicos, assim como novos manejos promissores na prevenção e tratamento deste agravo. Conclusão: Incipiente é o conhecimento dos enfermeiros sobre as medidas específicas diante do extravasamento de antineoplásicos, com evidente necessidade de pesquisas que minimizem as lacunas no conhecimento inovador na prática da enfermagem com desígnio de prevenir  o extravasamento.

Estudio sobre las características de la información sanitaria en las conducciones entre centros penitenciario / Study of the characteristics of medical information in transfers between prisons

Introducción: La movilidad de la población penitenciaria precisa que la información transmitida en los traslados entre centros garantice una óptima continuidad asistencial. Objetivo: Valorar la calidad de la transmisión de información sanitaria cuando los internos son trasladados en conducción entre centros penitenciarios de todo el territorio español. Material y método: Estudio observacional, descriptivo y transversal, consistente en la revisión de historias clínicas de los internos que transitaron por el Centro Penitenciario (CP) Madrid III en un periodo de tres meses. Todas las variables medidas fueron cualitativas, expresadas en frecuencias absolutas y relativas. Resultados: Durante ese tiempo, 1.168 internos transitaron por el CP Madrid III. Solo 21 procedían de centros penitenciarios de Cataluña, País Vasco o Navarra, cuya historia clínica es diferente a la del resto del Estado, y solo el 57,14% aportaban algún tipo de información sanitaria. Del resto de internos, el 70,79% aportaba algún tipo de información: el 63,90% del total tenía medicación prescrita y el 5% metadona. De aquellos que tenían medicación, el 89,10% la tenían prescrita en la prescripción electrónica, siendo correcta en el 98% de los casos. Respecto a la metadona, solo el 75,44% lo tenía prescrito electrónicamente, siendo correcta en todos los casos. La fecha de la última dosis administrada solo se indicó en el 72,40% de los tratamientos. Discusión: Solo el 34,70% de las historias presentaban una calidad óptima en cuanto a la información transmitida, siendo en el 2,50% de los casos la información recibida deficiente. El uso de herramientas informáticas facilita la transmisión de la información, reduce la carga de trabajo y mejora la seguridad del paciente.(AU)

Introduction: The mobility of the prison population creates a need for information transmitted in transfers between centers that can guarantee optimal care continuity. Objective: To assess the quality of transmission of health information when inmates are transferred between prisons in Spain. Material and method: Observational, descriptive and cross-sectional study, consisting of a review of medical records of inmates who passed through Madrid III Prison in a three-month period. All measured variables were qualitative, and were expressed in absolute and relative frequencies. Results: 1,168 inmates passed through Madrid III Prison in this period. Only 21 came from prisons in Catalonia, the Basque Country or Navarre, where their medical records are different from those in the rest of Spain, and only 57.14% provided some type of health information. Of the remaining inmates, 70.79% provided some type of information: 63.90% of the total had prescriptions for medication and 5% were prescribed with methadone. Of those taking medication, 89.10% were prescribed it in electronic prescriptions, which were correct in 98% of the cases. For methadone, only 75.44% had electronic prescriptions,which were correct in all cases. The date of the last dose administered was only indicated in 72.40% of the treatments. Discussion: Only 34.70% of the records presented optimal quality in terms of the information transmitted, and in 2.50% of the cases the information received was deficient. The use of computerized tools facilitates the transmission of information, reduces the workload and improves patient safety.(AU)

Validated medication deprescribing instruments for patients with palliative care needs: a systematic review / Instrumentos validados de desprescripción de medicamentos para los pacientes que reciben cuidados paliativos: una revisión sistemática

Objectives: Patients with life-limiting illnesses are prone to unnecessary polypharmacy. Deprescribing tools may contribute to minimizing negative outcomes. Thus, the aims of the study were to identify validated instruments for deprescribing inappropriate medications for patients with palliative care needs and to assess the impact on clinical, humanistic, and economic outcomes. Methods: A systematic review was conducted in LILACS, PUBMED, EMBASE, COCHRANE, and WEB OF SCIENCE databases (until May 2021). A manual search was performed in the references of enrolled articles. The screening, eligibility, extraction, and bias risk assessment were carried out by 2 independent researchers. Experimental and observational studies were eligible for inclusion. Results: Out of the 5791 studies retrieved, after excluding duplicates (n = 1050), conducting title/abstract screening (n = 4741), and full reading (n = 41), only 1 study met the inclusion criteria. In this included study, a randomized controlled trial was conducted, which showed a high level of bias risk overall. Adults 75 years or older (n = 130) with limited life expectancy and polypharmacy were allocated to 2 groups [intervention arm (deprescribing); and control arm (usual care)]. Deprescribing was performed with the aid of the STOPPFrail tool. The mean number of inappropriate medications and monthly medication costs were significantly lower in the intervention arm. No statistically significant differences were found in terms of unscheduled hospital presentations, falls, fractures, mortality, and quality of life. Conclusions: Despite the availability of several instruments to support deprescribing in patients with palliative care needs, only 1 of them has undergone validation and robust assessment for effectiveness in clinical practice. The STOPPFrail tool appears to reduce the number of inappropriate medications for older people with limited life expectancy (and probably palliative care needs)...(AU)

Objetivo: Los pacientes con enfermedades terminales son propensos a la polifarmacia innecesaria. Las herramientas de desprescripción pueden contribuir a minimizar los resultados negativos. Por lo tanto, los objetivos del estudio fueron identificar instrumentos validados para la desprescripción de medicamentos inapropiados en pacientes con necesidades de cuidados paliativos y evaluar el impacto en los resultados clínicos, humanísticos y económicos. Métodos: Se realizó una revisión sistemática en las bases de datos LILACS, PUBMED, EMBASE, COCHRANE y WEB OF SCIENCE (hasta mayo de 2021). Se realizó una búsqueda manual en las referencias de los artículos incluidos. La selección, elegibilidad, extracción y evaluación del riesgo de sesgo se llevaron a cabo por dos investigadores independientes. Se aceptó la inclusión de estudios observacionales y experimentales. Resultados: De los 5791 estudios recuperados, después de excluir duplicados (n = 1050), realizar la selección de títulos/resúmenes (n = 4741) y la lectura completa (n = 41), solo un estudio cumplió con los criterios de inclusión. En este estudio incluido, se realizó un ensayo controlado aleatorizado, que mostró un alto nivel de riesgo de sesgo en general. A los adultos de 75 años o más (n = 130) con esperanza de vida limitada y polifarmacia se les asignaron dos grupos [grupo de intervención (desprescripción) y grupo de control (atención habitual)]. Se realizó la desprescripción con la ayuda de la herramienta STOPPFrail. El número promedio de medicamentos inapropiados y los costos mensuales de los medicamentos fueron significativamente más bajos en el grupo de intervención. No se encontraron diferencias estadísticamente significativas en términos de presentaciones hospitalarias no programadas, caídas, fracturas, mortalidad y calidad de vida. Conclusiones: A pesar de la disponibilidad de varias herramientas para apoyar la deprescripción en pacientes con necesidades de cuidados paliativos...(AU)

Instrumentos validados de desprescripción de medicamentos para los pacientes que reciben cuidados paliativos: una revisión sistemática / Validated medication deprescribing instruments for patients with palliative care needs: a systematic review

Objectives: Patients with life-limiting illnesses are prone to unnecessary polypharmacy. Deprescribing tools may contribute to minimizing negative outcomes. Thus, the aims of the study were to identify validated instruments for deprescribing inappropriate medications for patients with palliative care needs and to assess the impact on clinical, humanistic, and economic outcomes. Methods: A systematic review was conducted in LILACS, PUBMED, EMBASE, COCHRANE, and WEB OF SCIENCE databases (until May 2021). A manual search was performed in the references of enrolled articles. The screening, eligibility, extraction, and bias risk assessment were carried out by 2 independent researchers. Experimental and observational studies were eligible for inclusion. Results: Out of the 5791 studies retrieved, after excluding duplicates (n = 1050), conducting title/abstract screening (n = 4741), and full reading (n = 41), only 1 study met the inclusion criteria. In this included study, a randomized controlled trial was conducted, which showed a high level of bias risk overall. Adults 75 years or older (n = 130) with limited life expectancy and polypharmacy were allocated to 2 groups [intervention arm (deprescribing); and control arm (usual care)]. Deprescribing was performed with the aid of the STOPPFrail tool. The mean number of inappropriate medications and monthly medication costs were significantly lower in the intervention arm. No statistically significant differences were found in terms of unscheduled hospital presentations, falls, fractures, mortality, and quality of life. Conclusions: Despite the availability of several instruments to support deprescribing in patients with palliative care needs, only 1 of them has undergone validation and robust assessment for effectiveness in clinical practice. The STOPPFrail tool appears to reduce the number of inappropriate medications for older people with limited life expectancy (and probably palliative care needs)...(AU)

Objetivo: Los pacientes con enfermedades terminales son propensos a la polifarmacia innecesaria. Las herramientas de desprescripción pueden contribuir a minimizar los resultados negativos. Por lo tanto, los objetivos del estudio fueron identificar instrumentos validados para la desprescripción de medicamentos inapropiados en pacientes con necesidades de cuidados paliativos y evaluar el impacto en los resultados clínicos, humanísticos y económicos. Métodos: Se realizó una revisión sistemática en las bases de datos LILACS, PUBMED, EMBASE, COCHRANE y WEB OF SCIENCE (hasta mayo de 2021). Se realizó una búsqueda manual en las referencias de los artículos incluidos. La selección, elegibilidad, extracción y evaluación del riesgo de sesgo se llevaron a cabo por dos investigadores independientes. Se aceptó la inclusión de estudios observacionales y experimentales. Resultados: De los 5791 estudios recuperados, después de excluir duplicados (n = 1050), realizar la selección de títulos/resúmenes (n = 4741) y la lectura completa (n = 41), solo un estudio cumplió con los criterios de inclusión. En este estudio incluido, se realizó un ensayo controlado aleatorizado, que mostró un alto nivel de riesgo de sesgo en general. A los adultos de 75 años o más (n = 130) con esperanza de vida limitada y polifarmacia se les asignaron dos grupos [grupo de intervención (desprescripción) y grupo de control (atención habitual)]. Se realizó la desprescripción con la ayuda de la herramienta STOPPFrail. El número promedio de medicamentos inapropiados y los costos mensuales de los medicamentos fueron significativamente más bajos en el grupo de intervención. No se encontraron diferencias estadísticamente significativas en términos de presentaciones hospitalarias no programadas, caídas, fracturas, mortalidad y calidad de vida. Conclusiones: A pesar de la disponibilidad de varias herramientas para apoyar la deprescripción en pacientes con necesidades de cuidados paliativos...(AU)

Papel del radiofarmacéutico clínico en la seguridad del paciente durante los estudios de perfusión miocárdica de esfuerzo con vasodilatadores / Role of the clinical radiopharmacist in patient safety during myocardial perfusion imaging with vasodilator stress agents

Objetivos: Evaluar el papel del radiofarmacéutico en un equipo multidisciplinar en la detección de contraindicaciones del regadenosón para su uso seguro en pacientes a los que se solicitó una SPECT de perfusión miocárdica. Métodos: Se estudió ambispectivamente su uso seguro en 1.905 pacientes (54,1% mujeres, edad media: 66,6±11,7 años, rango: 20-95años). Se registraron datos relativos al sexo, a la edad, al historial médico, a la medicación, a las alergias medicamentosas y a las contraindicaciones para el estrés farmacológico, así como las recomendaciones realizadas al médico nuclear responsable. Resultados: Las contraindicaciones detectadas y las correspondientes recomendaciones fueron las siguientes: riesgo de prolongación del intervalo QTc (7,5%): comprobación previa del intervalo QTc y monitorización del ECG; ictus o AIT previo (4,2%): evaluación de estenosis carotídea; alergia a salicilatos y/o sulfamidas (3,1%): empleo de [99mTc]Tc-MIBI; epilepsia o riesgo de convulsiones (2,4%): uso de adenosina o reconsiderar su indicación; tratamiento con corticosteroides sistémicos en EPOC severa (1,3%): reevaluar las condiciones del paciente; EPOC reagudizada (0,8%): posponer hasta la resolución del episodio agudo; asma grave (0,4%): no realizar la prueba; toma de metilxantinas (0,3%): evitar su consumo previo; otras (6,1%): evaluación de cada contraindicación. No se observaron contraindicaciones en el 73,6% de los pacientes. Se anularon el 2,9% de las peticiones debido a contraindicaciones absolutas. Conclusiones: Empleando una metodología de trabajo sistemática, el radiofarmacéutico detectó un elevado número de incidencias, presentando uno de cada cuatro pacientes alguna contraindicación clínica. Las recomendaciones emitidas fueron aceptadas por los médicos nucleares, que modificaron su enfoque, incrementando así la seguridad de estos pacientes.(AU)

Aim: To assess the radiopharmacist's role in a multidisciplinary team focused on the contraindications of regadenoson in order to ensure the safe use of pharmacologic vasodilator stress agents in patients undergoing SPECT-MPI. Methods: We ambispectively studied its safe use in 1905 patients (54.1% female, mean age: 66.6±11.7 years, range: 20-95years). Sex, age, medical history, medications, drug allergies, and contraindications for stress testing were registered together with recommendations for the nuclear physician in charge. Results: Detected contraindications and corresponding recommendations were as follows: risk factors for QTc interval prolongation 7.5% — measurement of QTc interval previously to test and monitor ECG; prior stroke or TIA 4.2% — consider carotid stenosis assessment; salicylates/sulfonamides allergy 3.1% — use 99mTc-sestamibi; epilepsy or risk factors for seizures 2.4% — use of adenosine or reconsider test indication; systemic corticosteroid therapy for severe COPD 1.3% — reassessment of patient's condition; acute exacerbation of COPD 0.8% — defer test until acute episode is over; severe asthma 0.4% — do not perform test; methylxanthine ingestion 0.3% — avoid consumption previously; other 6.1% — evaluation of other contraindications. No contraindications were detected in 73.6% of patients. The test was cancelled due to absolute contraindications in 2.9% of the requests. Conclusions: Working in a systematic way, the radiopharmacist was able to detect a high number of issues related to regadenoson, with one out of four patients presenting some clinical contraindication. The recommendations given by the radiopharmacist were well accepted by the nuclear physicians who changed their approach contributing to increase the safety of patients referred for MPI.(AU)

Detection and reduction of errors in parenteral nutrition compounding through gravimetric and product control. / [Artículo traducido] Detección y reducción de errores en la elaboración de la nutrición parenteral mediante control gravimétrico y de producto.

OBJECTIVE: To analyze the errors in the preparation of parenteral nutrition in a Pharmacy Service, detected through an already consolidated gravimetric and product quality control, and compare them with those detected during the initial years of implementing this quality control. METHODS: All errors detected through quality control in the compounding of pediatric and adult parenteral nutrition between 2019 and 2021 were prospectively analyzed. This quality control consisted of 3 sequential processes: a visual check, a gravimetric control, and a product control. Errors were classified as gravimetric, when the nutrition had a deviation of more than 5% from the theoretical weight, or as product errors when a qualitative or quantitative error was detected upon reviewing the remainder of the components used. These errors were analyzed in terms of type and the component involved. A comparison was made with the errors detected during the implementation phase of this quality control from 2016 to 2018. RESULTS: A total of 41,809 parenteral nutritions were reviewed, and 345 errors were detected (0.83% of the preparations); of these, 59 errors were found in pediatric nutritions (0.68% of them), and 286 in adult nutritions (0.86% of them). Among these errors, 193 were of gravimetric nature, while 152 were detected through product control. The main components involved in product errors were electrolytes, primarily due to the addition of excessive volumes and the use of incorrect components. A significant absolute reduction of 0.71% (p < 0.05) in the total number of errors was observed when compared to the implementation phase. This reduction was consistent in both gravimetric errors (-0.59%) and product-related errors (-0.12%) (p < 0.05). CONCLUSIONS: Comprehensive quality control of parenteral nutrition preparation is an easily implementable tool that effectively detected and prevented significant errors. Furthermore, its widespread adoption contributed to a reduction in the overall error count.

Presence of metallic components in transdermal drug delivery systems and risk of skin burns. / [Artículo traducido] Presencia de partículas metálicas en parches transdérmicos de medicamentos y riesgo de quemaduras.

OBJECTIVE: Skin burns are associated with the presence of metallic components in transdermal drug delivery systems during Magnetic Resonance Imaging, cardioversion or defibrillation procedures. The aim of the study was to review the presence of metallic components in marketed products of transdermal drug delivery systems in Spain. METHOD: For each presentation, the summary of product characteristics was reviewed. If the information was not provided, manufacturers were contacted. RESULTS: We identified 59 marketed products of transdermal drug delivery systems of 12 different active substances. 59.3% of patches contained metallic components or their presence could not be ruled out. Information regarding the need to remove the patch was only included in 8 summaries of product characteristics (13.6%). A table was elaborated and included the following aspects: product, active substance, manufacturer, need to remove the patch before the exposure to magnetic or electric fields and references. CONCLUSION: More than a half of the patches at the time of the study contained metals or their absence could not be confirmed by the manufacturer. However, this information was only included in 13.6% of summaries of product characteristics.

Impacto de la implementación de un método de traspaso de información estandarizada interdisciplinar en sala de partos y unidad de cuidados obstétricos intermedios / Impact of the implementation of a standardised interdisciplinary information transfer method in the Delivery room and Intermediate Obstetric Care Unit

Objetivo Este estudio tiene como objetivo describir la implementación de la metodología estandarizada en la transferencia de información en sala de partos y unidad de cuidados obstétricos intermedios en un hospital de tercer nivel de Barcelona e identificar el impacto de esta implementación en los factores que actúan como facilitadores y barreras en el procedimiento. Método Estudio cuasiexperimental tipo pretest-postest sin grupo control en la unidad de cuidados obstétricos intermedios y sala de partos del servicio de Medicina Maternofetal de un hospital de tercer nivel de Barcelona. El personal sanitario autocumplimentó un cuestionario ad hoc antes y después de implementar la metodología estandarizada IDEAS en el servicio durante 2019 y 2020. Se evaluó la autopercepción personal en el procedimiento de transferencia de información. El test de Wilcoxon por pares se utilizó para la comparación antes y después. Resultados El uso de una metodología estandarizada ha mostrado un impacto en la mejora de la transmisión de la información. Se detectaron diferencias significativas antes y después de la intervención en las siguientes dimensiones: ubicación, personas implicadas, periodo de tiempo del procedimiento, estructurada ordenada y clara y tiempo suficiente para preguntas (p<0,001); mientras que no se observaron diferencias en transmisión al profesional referente, actuaciones bien definidas y realización de un resumen. Conclusiones Existen factores, como aspectos estructurales, organizativos y falta de tiempo, que dificultan la comunicación efectiva, por tanto, actúan como barreras en la transferencia de información. La implementación de una metodología con las personas implicadas, el tiempo y el espacio adecuado permite mejorar aspectos en la comunicación en el equipo multiprofesional y, por tanto, la seguridad del paciente. (AU)

Aim This study aims to describe the implementation of the standard methodology for information transfer in the labour ward and Intermediate Obstetric Care Unit and to identify the impact of this implementation on the factors that act as facilitators and barriers in the procedure. Method Quasi-experimental pretest-posttest study without a control group in an Intermediate Obstetric Care Unit and delivery room of the Maternal-Fetal Medicine Service of a tertiary hospital in Barcelona. Healthcare staff self-completed an ad hoc questionnaire before and after implementing the standardised IDEAS methodology in the service during 2019 and 2020. Personal self-perception in the information transfer procedure was assessed. The Wilcoxon pairwise test was used for comparison before and after. Results The use of a standardised methodology has shown an impact on improving the transmission of information. Significant differences were detected before and after the intervention in the following dimensions: location, people involved, time period of the procedure, structured, orderly and clear, and sufficient time for questions (p<0.001); while no differences were observed in: transmission to the referring professional, well-defined actions, and completion of a summary. Conclusions There are factors such as structural and organisational aspects and lack of time that hinder effective communication and therefore act as barriers to the transfer of information. The implementation of a methodology with the health professionals involved, the time and the appropriate space allows for the improvement of communication aspects in the multiprofessional team and, therefore, patient safety. (AU)

Impacto de la implementación de un método de traspaso de información estandarizada interdisciplinar en sala de partos y unidad de cuidados obstétricos intermedios / Impact of the implementation of a standardised interdisciplinary information transfer method in the Delivery room and Intermediate Obstetric Care Unit

Objetivo Este estudio tiene como objetivo describir la implementación de la metodología estandarizada en la transferencia de información en sala de partos y unidad de cuidados obstétricos intermedios en un hospital de tercer nivel de Barcelona e identificar el impacto de esta implementación en los factores que actúan como facilitadores y barreras en el procedimiento. Método Estudio cuasiexperimental tipo pretest-postest sin grupo control en la unidad de cuidados obstétricos intermedios y sala de partos del servicio de Medicina Maternofetal de un hospital de tercer nivel de Barcelona. El personal sanitario autocumplimentó un cuestionario ad hoc antes y después de implementar la metodología estandarizada IDEAS en el servicio durante 2019 y 2020. Se evaluó la autopercepción personal en el procedimiento de transferencia de información. El test de Wilcoxon por pares se utilizó para la comparación antes y después. Resultados El uso de una metodología estandarizada ha mostrado un impacto en la mejora de la transmisión de la información. Se detectaron diferencias significativas antes y después de la intervención en las siguientes dimensiones: ubicación, personas implicadas, periodo de tiempo del procedimiento, estructurada ordenada y clara y tiempo suficiente para preguntas (p<0,001); mientras que no se observaron diferencias en transmisión al profesional referente, actuaciones bien definidas y realización de un resumen. Conclusiones Existen factores, como aspectos estructurales, organizativos y falta de tiempo, que dificultan la comunicación efectiva, por tanto, actúan como barreras en la transferencia de información. La implementación de una metodología con las personas implicadas, el tiempo y el espacio adecuado permite mejorar aspectos en la comunicación en el equipo multiprofesional y, por tanto, la seguridad del paciente. (AU)

Aim This study aims to describe the implementation of the standard methodology for information transfer in the labour ward and Intermediate Obstetric Care Unit and to identify the impact of this implementation on the factors that act as facilitators and barriers in the procedure. Method Quasi-experimental pretest-posttest study without a control group in an Intermediate Obstetric Care Unit and delivery room of the Maternal-Fetal Medicine Service of a tertiary hospital in Barcelona. Healthcare staff self-completed an ad hoc questionnaire before and after implementing the standardised IDEAS methodology in the service during 2019 and 2020. Personal self-perception in the information transfer procedure was assessed. The Wilcoxon pairwise test was used for comparison before and after. Results The use of a standardised methodology has shown an impact on improving the transmission of information. Significant differences were detected before and after the intervention in the following dimensions: location, people involved, time period of the procedure, structured, orderly and clear, and sufficient time for questions (p<0.001); while no differences were observed in: transmission to the referring professional, well-defined actions, and completion of a summary. Conclusions There are factors such as structural and organisational aspects and lack of time that hinder effective communication and therefore act as barriers to the transfer of information. The implementation of a methodology with the health professionals involved, the time and the appropriate space allows for the improvement of communication aspects in the multiprofessional team and, therefore, patient safety. (AU)

Prevalencia de caídas en pacientes ingresados en un hospital universitario / Prevalence of falls in patients admitted to a University Hospital

Objetivo: analizar la prevalencia de caídas de los pacientes hos­pitalizados en un hospital universitario, así como los factores asociados con la asistencia sanitaria (motivos de las caídas, especialidad más prevalente, turno más frecuente, si estaban solos o acompañados, etc.) en los pacientes que se cayeron y las posibles consecuencias de las caídas. Métodos: estudio transversal. Se incluyeron a todos los pacientes adultos ingresados en 20 unidades de hospitalización del Hospital Universitario de Burgos, que habían sufrido una caída en 2019 y estaban incluidos en el registro de caídas del programa GACELA Care®. El formulario consta de 28 campos de en­trada de datos, que aportan información relevante sobre la caída. Se llevó a cabo análisis descriptivo y comparativo, usando los test estadísticos correspondientes. Resultados: se registraron 244 caídas (0,9%). La edad media fue 73,3 años. El 54,4% tenía edad igual o mayor a 75 años. El 57,8% era del sexo masculino. En Medicina Interna (29,1%) y Psiquiatría (11,1%) se registró el mayor porcentaje de caídas. El 44,2% se produjo en turno de noche, en pacientes que estaban solos (71,7%), sin protecciones (70,5%); y deambulando (36,1%). El motivo principal fue la inestabilidad motora (48,4%). El 62,7% de los pacientes resultó ileso. La especialidad y el turno de trabajo se asociaron significativamente con las caídas. Conclusiones: la prevalencia de caídas en el hospital fue baja. Los factores que se relacionaron con mayor porcentaje de caídas fueron ser mayor de 75 años, sexo masculino, estar ingresado en unidades de especialidad médica y turno de noche. Las caídas ocurrieron habitualmente cuando el paciente estaba solo, sin protección, al levantarse y caminar. La mayoría de los pacientes no presentó lesiones.(AU)

Objective: to analyse the prevalence of falls in patients admitted to a University Hospital, as well as to identify the characteristics of those patients who experienced falls, the factors associated with patient care (reasons for falls, the most prevalent specialty, the most frequent shift, whether they were alone or accompanied, etc.) among patients who fell down, and the potential consequences of said falls. Methods: a cross-sectional study, including all adult patients admitted to 20 hospitalization units from the Hospital Universitario de Burgos, who had experienced a fall in 2019 and were included in the register of falls from the GACELA Care® program. The form consisted of 28 data entry fields, and included information about date, time and place of the fall; reasons for falls; consequences of falls, and action by professionals. Descriptive and comparative analysis was conducted, using the relevant statistical tests. Results: in total, 244 (0.9%) falls were registered. The mean age was 73.3 years; 57.8% were male. The highest proportion of falls was recorded at Internal Medicine (29.1%) and Psychiatry (11.1%); 44.2% occurred during the night shift, in patients who were alone (71.7%); without protections (70.5%); and walking around (36.1%). The main reason was motor instability (48,4%); 62.7% of patients remained unharmed. There was a significant association between specialty and work shift and falls. Conclusions: there was a low prevalence of falls in the hospital. The factors associated with a higher proportion of falls were being >75-year-old, male gender, being admitted to medical specialty units, and night shift. Falls commonly occurred when the patient was alone, without protection, when getting up and walking. Most patients did not present any lesions.(AU)

Manejo de PICC en el Servicio de Urgencias de un hospital universitario / Use of PICC at the University Hospital Emergency Unit

Para gestionar el capital venoso del paciente con seguridad y responsabilidad es necesario aumentar la calidad de los cuidados proporcionados, unificando y estandarizando los criterios de actuación, basándose siempre en la mejor evidencia científica. Las enfermeras de los Servicios de Urgencias deben aplicar la evidencia en el manejo del catéter venoso central de inserción periférica (PICC), conocer el protocolo aprobado por la Dirección Asistencial de su hospital y, sobre todo, evitar la variabilidad en la actuación, que podría aumentar los riesgos relacionados con la atención sanitaria, así como la desconfianza del paciente. Mantener actualizados los conocimientos y promover la adquisición de habilidades en la práctica clínica es de suma importancia para garantizar cuidados de calidad en el manejo de este tipo de catéteres, debiéndose comprobar periódicamente el grado de cumplimiento de la evidencia recogida en los protocolos existentes en el hospital. Las enfermeras tienen el reto de estar al día en el manejo de los accesos vasculares, y deben responder con seriedad y evidencia a los cuidados que necesitan los pacientes a los que se atienden. En este manuscrito se objetiva la necesidad de formar y capacitar de forma continua a los profesionales para el manejo adecuado del PICC. (AU)

In order to manage the venous resource of the patient safely and with responsibility, it is necessary to increase the quality of care provided, unifying and standardizing performance criteria, always based on the best scientific evidence. Emergency Unit nurses must apply evidence in their use of the peripherally inserted central venous catheter (PICC), they must know the protocol approved by the Patient Care Management in their hospital and, most of all, must avoid variability of action, which could increase the risks associated with healthcare as well as mistrust by patients. It is extremely important to keep an updated knowledge and to promote the acquisition of clinical practice skills, in order to guarantee quality care in the use of this type of catheters; the level of compliance of the evidence collected in the hospital protocols must be confirmed periodically. Nurses face the challenge of being updated in the management of vascular accesses, and must give response with seriousness and evidence to the care needed by their patients. This manuscript sets out objectively the need for continuous training and qualification for professionals regarding the adequate use of PICC. (AU)

Eficacia y seguridad de la vacunación antigripal pediátrica: una revisión sistemática / Efficacy and safety of pediatric flu vaccination: a systematic review

Introducción. Los a corren un mayor riesgo de infección por influenza en comparación con la población general. La Organización Mundial la Salud y las recomendaciones del Comité Asesor de Vacunas de la Asociación Española de Pediatría contemplan la vacunación anual como la forma más eficaz de prevenir la enfermedad. Por lo tanto, el propósito de esta revisión fue actualizar la información sobre eficacia y seguridad en la vacuna antigripal en niños y adolescentes. Material y métodos. Una búsqueda en cuatro bases de datos electrónicas (Scopus, Cumulative Index to Nursing and Allied Health Literature, MedLine / PubMed, Google Scholar y Cochrane), así como una búsqueda manual para identificar investigaciones originales publicadas entre 2012 y 2022. Se adoptaron las directrices de análisis (PRISMAcR) como elemento de informe preferido para revisiones sistemáticas. Resultados. Se incluyeron siete artículos de investigación originales donde se identificaron dos temas de la vacunación antigripal en niños/adolescentes sanos y con patologías. La eficacia (entre un 30% y un 80% aproximadamente) varió en función de la vacuna utilizada y los subtipos circulantes. La mayoría de las reacciones adversas fueron de intensidad leve y el evento adverso local más común informado fue dolor en el sitio de la inyección. Conclusiones. Destacamos positivamente la seguridad de la vacunación antigripal pediátrica en los estudios analizados, por el contrario, con respecto a la eficacia de la vacunación antigripal, observamos una amplia variabilidad de resultados. Existe una clara necesidad de seguir realizando estudios de eficacia y seguridad en el niño. (AU)

Introduction. Children are at a higher risk of influenza infection compared to the general population. The World Organization Health and recommendations of the Vaccine Advisory Committee of the Spanish Association of Pediatrics contemplate annual vaccination as the most effective way to prevent the disease. Therefore, the purpose of this review was to update information on efficacy and safety in the anti -shed vaccine in children and adolescents. Material and methods. A search in four electronic databases (Scopus, Cumulative Index to Nursing and Allied Health Literature, Medline / Pubmed, Google Scholar and Cochrane), as well as a manual search to identify original research published between 2012 and 2022. The guidelines of ANALYSIS (PRISMACR) as a preferred report element for systematic reviews. Results. Seven original research articles were included where two issues of antigripal vaccination were identified in healthy children/adolescents and with pathologies. The efficacy (between approximately 30% and 80%) varied depending on the vaccine used and circulating subtypes. Most adverse reactions were mild intensity, and the most common local adverse event was pain in the injection site. Conclusions. We positively highlight the safety of pediatric flu vaccination in analyzed studies, on the contrary, with respect to the efficacy of flu vaccination, we observe a wide variability of results. There is a clear need to continue conducting efficacy and safety studies in the child. (AU)

Cuidados de enfermagem no banho de aspersão em instituição de longa permanência: revisão integrativa / Nursing care in the spray bath in a long-term care institution: integrative review

Identificar os cuidados de enfermagem necessários para o banho de aspersão seguro para idosos no quotidiano de uma instituição de longa permanência. Método: Revisão Integrativa da literatura, recorte entre 2001 e 2022. Os dados dos estudos incluídos resultaram em uma síntese descritiva, fundamentada na Teoria das Necessidades Humanas Básicas. Resultados: Obteve-se 13 estudos sobre cuidados no banho com e sem auxílio, envolvendo o equilíbrio psicobiológico, psicossocial e psicoespiritual, remoção de barreiras ambientais, adaptação domiciliar, maneiras de abordagem, musicoterapia e cuidados com a integridade da pele, oportunizando segurança e qualidade nas ações prestadas. Conclusões: Os cuidados precisam estar integrados às necessidades humanas básicas, respeitando as peculiaridades do processo de envelhecimento e as fragilidades dos idosos mais vulneráveis. A qualificação dos profissionais de enfermagem/cuidadores formais visa a padronização da execução do procedimento e a redução de ocorrência de desvios de procedimento.(AU)

To identify the nursing care necessary for safe spray baths for elderly people in daily life in a long-term care institution. Method: Integrative literature review, cut between 2001 and 2022. Data from the included studies resulted in a descriptive synthesis, based on the Theory of Basic Human Needs. Results: 13 studies were obtained on bath care with and without assistance, involving psychobiological, psychosocial and psychospiritual balance, removal of environmental barriers, home adaptation, approaches, music therapy and care for the integrity of the skin, providing safety and quality in the actions provided. Conclusions: Care needs to be integrated with basic human needs, respecting the peculiarities of the aging process and the weaknesses of the most vulnerable elderly people. The qualification of nursing professionals/formal caregivers aims to standardize the execution of the procedure and reduce the occurrence of procedural deviations.(AU)

Identificar los cuidados de enfermería necesarios para baños de aspersión seguros para personas mayores en la vida diaria en una institución de cuidados a largo plazo. Método: Revisión integrativa de la literatura, cortada entre 2001 y 2022. Los datos de los estudios incluidos resultaron en una síntesis descriptiva, basada en la Teoría de las Necesidades Humanas Básicas. Resultados: Se obtuvieron 13 estudios sobre cuidados del baño con y sin asistencia, involucrando equilibrio psicobiológico, psicosocial y psicoespiritual, remoción de barreras ambientales, adaptación domiciliaria, abordajes, musicoterapia y cuidado de la integridad de la piel, brindando seguridad y calidad en las acciones. proporcionó. Conclusiones: Los cuidados deben integrarse con las necesidades humanas básicas, respetando las peculiaridades del proceso de envejecimiento y las debilidades de las personas mayores más vulnerables. La calificación de los profesionales de enfermería/cuidadores formales tiene como objetivo estandarizar la ejecución del procedimiento y reducir la ocurrencia de desviaciones procesales.(AU)

Why do physicians go to work when they are sick? Presenteeism at different career stages.

INTRODUCTION AND OBJECTIVE: Physicians find it difficult to take on the role of the patient and they show unusual behaviors when ill. One of these behaviors is presenteeism, which is working while sick. The objective of this research is to analyze the factors that contribute to the phenomenon of presenteeism in Spanish physicians. MATERIAL AND METHODS: Mixed methodology study: one national survey through the General Council of Medical Associations website (quantitative part), 22 semistructured interviews with sick residents and practicing physicians, and three focus groups involving professionals from the occupational health services (qualitative). A bivariate analysis using parametric and non-parametric tests. The significance level was p<0.05 (95% confidence interval). Qualitative analysis using the comparative-constant method until saturation of information. RESULTS: Presenteeism is reported by 89.4% of doctors who responded to the survey, and it is more common among women. Contributing factors include fear of overburdening colleagues (the main reason and more common among women 58.14% vs 48.35%), self-perception of doing one's duty (the second reason and more common among men, 44.63% vs 33.14%) and economic impact and difficulty in accepting the role of a sick person. This behavior has an impact on patient safety, and is part of the hidden curriculum that also affects the training of medical professionals. CONCLUSIONS: Presenteeism is a widespread and accepted practice among medical professionals. Although normalized, and even appreciated as a way to avoid overburdening colleagues, presenteeism has important implications for clinical ethics and patient safety.

Role of the clinical radiopharmacist in patient safety during myocardial perfusion imaging with vasodilator stress agents.

AIM: To assess the radiopharmacist's role in a multidisciplinary team focused on the contraindications of regadenoson in order to ensure the safe use of pharmacologic vasodilator stress agents in patients undergoing SPECT-MPI. METHODS: We ambispectively studied its safe use in 1905 patients (54.1% female, mean age: 66.6±11.7 years, range: 20-95 years). Sex, age, medical history, medications, drug allergies, and contraindications for stress testing were registered together with recommendations for the nuclear physician in charge. RESULTS: Detected contraindications and corresponding recommendations were as follows: risk factors for QTc interval prolongation 7.5% - measurement of QTc interval previously to test and monitor ECG; prior stroke or TIA 4.2% - consider carotid stenosis assessment; salicylates/sulfonamides allergy 3.1% - use 99mTc-sestamibi; epilepsy or risk factors for seizures 2.4% - use of adenosine or reconsider test indication; systemic corticosteroid therapy for severe COPD 1.3% - reassessment of patient's condition; acute exacerbation of COPD 0.8% - defer test until acute episode is over; severe asthma 0.4% - do not perform test; methylxanthine ingestion 0.3% - avoid consumption previously; other 6.1% - evaluation of other contraindications. No contraindications were detected in 73.6% of patients. The test was canceled due to absolute contraindications in 2.9% of the requests. CONCLUSIONS: Working in a systematic way, the radiopharmacist was able to detect a high number of issues related to regadenoson, with one out of four patients presenting some clinical contraindication. The recommendations given by the radiopharmacist were well accepted by the nuclear physicians who changed their approach contributing to increase the safety of patients referred for MPI.

Estrategias para garantizar la seguridad del paciente crítico / Strategies to ensure the critical patient safety

Objetivo: Identificar las estrategias para garantizar la seguridad del paciente crítico. Método: Revisión integradora, cuya búsqueda fue realizada en mayo del 2022 haciendo uso de las fuentes de datos: MEDLINE, SciELO, WOS, LILACS, Scopus e IBECS. El análisis y síntesis se construyó a partir de los resultados encontrados, buscando agruparlos por categorías en función de la similitud de contenido. Resultados: Se encontraron 377 artículos, luego se procedió a aplicar los criterios de inclusión y la lectura exhaustiva, resultando una muestra de 13 artículos. Los resultados fueron clasificados en cinco categorías: Prevención de la neumonía asociada a la ventilación mecánica; Seguridad en la administración y gestión de medicamentos; Prevención de las lesiones por presión; Programa educativo orientado a la seguridad del paciente en cuidados intensivos, y Reflexiones del equipo de salud con respecto a cultura de seguridad.Conclusiones: Este estudio contribuye a identificar de forma integral las diversas estrategias cuyos resultados demostraron un cambio positivo en la prevención de eventos adversos y el fortalecimiento en la seguridad en la atención sanitaria (AU)

Objective: Identify the strategies to guarantee the safety of the critically ill patient. Method: Integrative review, search carried out in May 2022 using the data sources: MEDLINE, SciELO, WOS, LILACS, Scopus and IBECS. The analysis and synthesis were built from the results found, seeking to group them by categories based on the similarity of content. Results: 377 articles were found, thenthe inclusion criteriaand exhaustive reading were applied, resulting in a sample of 13 articles. The results were classified into five categories: Prevention of pneumonia associated with mechanical ventilation; Safety in the administration of management of medicines; Prevention of pressure injuries; Educational program oriented to patient safety in intensive care and; Reflections of the health team regarding safety culture. Conclusions: This study contributes to comprehensively identify the various strategies whose results demonstrated a positive change in the prevention of adverse events and strengthening of safety in health care (AU)