Is primary care a patient-safe setting? Prevalence, severity, nature, and causes of adverse events: numerous and mostly avoidable.

Knowing the frequency and characteristics of adverse events (AEs) is key to implementing actions that can prevent their occurrence. However, reporting systems are insufficient for this purpose and epidemiological studies are also required. Currently, the reviewing of clinical records is the gold standard method for knowing the frequency and characteristics of AEs. Research on AEs in a primary care setting has been limited and primarily focuses on specific types of events (medication errors, etc.) or patients. Large studies that search for any kind of AE in all patients are scarce. This study aimed to estimate the prevalence of AEs in the primary care setting and their characteristics. SETTING: all 262 primary health-care centres in the Madrid region (Spain) during the last quarter of 2018. DESIGN: cross-sectional descriptive study. Eligible population: subjects over 18 years of age who attended medical consultation over the last year (N = 2 743 719); a randomized sample stratified by age. MAIN OUTCOMES: age, sex, occurrence of an AE, number of consultations in the study period, avoidability, severity, place of occurrence, type of event, and contributory factors. The clinical records were reviewed by three teams, each composed of one doctor and one nurse trained and with expertise in patient safety. The SPSS software package (version 26) was used for the statistical analyses. The evaluators reviewed 1797 clinical records. The prevalence of AEs over the study period was 5.0% [95% confidence interval (CI): 4.0%‒6.0%], with higher values in women (5.7%; 95% CI: 4.6%‒6.8%;P = 0.10) and patients over 75 years of age (10.3%; 95% CI: 8.9%‒11.7%; P < 0.001). The overall occurrence per hundred consultations was estimated to be 1.58% (95% CI: 1.28%‒1.94%). Of the detected AEs, 71.3% (95% CI: 62.1%‒80.5%) were avoidable. Additionally, 60.6% (95% CI: 50.7%‒70.5%) were categorized as mild, 31.9% (95% CI: 22.4%‒41.4%) as moderate, and 7.4% (95% CI: 2.1%‒12.7%) as severe. Primary care was the occurrence setting in 76.6% (95% CI: 68.0%‒85.2%) of cases. The overall incidence of AEs related to medication was 53.2% (95% CI: 50.9%‒55.5%). The most frequent types of AEs were prescription errors (28.7%; 95% CI: 19.5%‒37.9%), followed by drug administration errors by patients (17.0%; 95% CI: 9.4%‒24.6%), and clinical assessment errors (11.7%; 95% CI: 5.2%‒18.2%). The most common contributory factors were those related to the patient (80.6%; 95% CI: 71.1%‒90.1%) and tasks (59.7%; 95% CI: 48.0%‒71.4%). A high prevalence of AEs (1 in 66 consultations) was observed, which was slightly higher than that reported in similar studies. About 3 out of 4 such events were considered to be avoidable and 1 out of 13 was severe. Prescription errors, drug administration errors by patients, and clinical assessment errors were the most frequent types of AEs. Graphical Abstract.

Validation of a Reduced Set of High-Performance Triggers for Identifying Patient Safety Incidents with Harm in Primary Care: TriggerPrim Project.

OBJECTIVE: The aim of the study was to construct and validate a reduced set of high-performance triggers for identifying adverse events (AEs) via electronic medical records (EMRs) review in primary care (PC). METHODS: This was a cross-sectional descriptive study for validating a diagnostic test. The study included all 262 PC centers of Madrid region (Spain). Patients were older than 18 years who attended their PC center over the last quarter of 2018. The randomized sample was n = 1797. Main measurements were as follows: ( a ) presence of each of 19 specific computer-identified triggers in the EMR and ( b ) occurrence of an AE. To collect data, EMR review was conducted by 3 doctor-nurse teams. Triggers with statistically significant odds ratios for identifying AEs were selected for the final set after adjusting for age and sex using logistic regression. RESULTS: The sensitivity (SS) and specificity (SP) for the selected triggers were: ≥3 appointments in a week at the PC center (SS = 32.3% [95% confidence interval {CI}, 22.8%-41.8%]; SP = 92.8% [95% CI, 91.6%-94.0%]); hospital admission (SS = 19.4% [95% CI, 11.4%-27.4%]; SP = 97.2% [95% CI, 96.4%-98.0%]); hospital emergency department visit (SS = 31.2% [95% CI, 21.8%-40.6%]; SP = 90.8% [95% CI, 89.4%-92.2%]); major opioids prescription (SS = 2.2% [95% CI, 0.0%-5.2%]; SP = 99.8% [95% CI, 99.6%-100%]); and chronic benzodiazepine treatment in patients 75 years or older (SS = 14.0% [95% CI, 6.9%-21.1%]; SP = 95.5% [95% CI, 94.5%-96.5%]).The following values were obtained in the validation of this trigger set (the occurrence of at least one of these triggers in the EMR): SS = 60.2% (95% CI, 50.2%-70.1%), SP = 80.8% (95% CI, 78.8%-82.6%), positive predictive value = 14.6% (95% CI, 11.0%-18.1%), negative predictive value = 97.4% (95% CI, 96.5%-98.2%), positive likelihood ratio = 3.13 (95% CI, 2.3-4.2), and negative likelihood ratio = 0.49 (95% CI, 0.3-0.7). CONCLUSIONS: The set containing the 5 selected triggers almost triples the efficiency of EMR review in detecting AEs. This suggests that this set is easily implementable and of great utility in risk-management practice.

[Evaluation of hand hygiene compliance in a Primary Health Care area of Madrid]. / Evaluación del cumplimiento de higiene de las manos en un área de atención primaria de Madrid.

INTRODUCTION: Hand hygiene is the most effective measure for preventing infections related to healthcare. This study aims to evaluate the Hand hygiene compliance in Primary Health Care. METHODS: A cross-sectional study was carried out, collecting socio-demographic data and the hand hygiene compliance from 198 Primary Health Care workers. Their hand hygiene compliance was evaluated according to WHO criteria. RESULTS: The level of hand hygiene compliance was 8.1% (95% CI 6.2-10.1). Employment experience of over 20 years was significantly associated with low levels of compliance. CONCLUSION: Primary Health Care workers have a low hand hygiene compliance. Training programs need to be introduced to increase compliance and facilitate access to hydro-alcoholic solutions.

Effectiveness of a training programme to improve hand hygiene compliance in primary healthcare.

BACKGROUND: Hand hygiene is the most effective measure for preventing infections related to healthcare, and its impact on the reduction of these infections is estimated at 50%. Non-compliance has been highlighted in several studies in hospitals, although none have been carried out in primary healthcare. MAIN OBJECTIVE: To evaluated the effect of a "Hand Hygiene for the reduction of healthcare-associated infections" training program for primary healthcare workers, measured by variation from correct hand hygiene compliance, according to regulatory and specific criteria, 6 months after the baseline, in the intervention group (group receiving a training program) and in the control group (a usual clinical practice). SECONDARY OBJECTIVES: -To describe knowledges, attitudes and behaviors as regards hand hygiene among the professionals, and their possible association with "professional burnout", stratifying the results by type of group (intervention and usual clinical practice).-To estimate the logistic regression model that best explains hand hygiene compliance. METHODS/DESIGN: Experimental study of parallel groups, with a control group, and random assignment by Health Center.Area of study.- Health centers in north-eastern Madrid (Spain).Sample studied.- Healthcare workers (physicians, odontostomatologists, pediatricians, nurses, dental hygienists, midwife and nursing auxiliaries).Intervention.- A hand hygiene training program, including a theoretical-practical workshop, provision of alcohol-based solutions and a reminder strategy in the workplace.Other variables: sociodemographic and professional knowledges, attitudes, and behaviors with regard to hand hygiene. STATISTICAL ANALYSIS: descriptive and inferential, using multivariate methods (covariance analysis and logistic regression). DISCUSSION: This study will provide valuable information on the prevalence of hand hygiene non-compliance, and improve healthcare.

[Working with the scientific method]. / Trabajar con método científico.

In order to improve the quality of nursing service provided to patients, the Nursing Directors for Area 7 Primary Health Care "IMSALUD" in Madrid drew up a work plan based, fundamentally, on a progressive installation of the scientific method in habitual nursing work. This transversal descriptive study measures the degree of installation of this method 18 months after the development of this plan and compares these results with those obtained 6 months after the development of this plan. After 18 months, Nursing Directors had planned to obtain a 50% complete compliance in the nursing process for immobilized and terminal patients. This objective has been achieved in terms of an evaluation by patterns and a register of nursing diagnosis. Improvement is needed in compliance of treatment plans and in recording evaluations in clinical files.

Cluster randomized trial to evaluate the effect of a multimodal hand hygiene improvement strategy in primary care.

OBJECTIVE: To evaluate the effectiveness of a multimodal intervention in primary care health professionals for improved compliance with hand hygiene practice, based on the World Health Organization's 5 Moments for Health Hygiene. DESIGN: Cluster randomized trial, parallel 2-group study (intervention and control). SETTING: Primary healthcare centers in Madrid, Spain. PARTICIPANTS: Eleven healthcare centers with 198 healthcare workers (general practitioners, nurses, pediatricians, auxiliary nurses, midwives, odontostomatologists, and dental hygienists). Methods. The multimodal hand hygiene improvement strategy consisted of training of healthcare workers by teaching sessions, implementation of hydroalcoholic solutions, and installation of reminder posters. The hand hygiene compliance level was evaluated by observation during regular care activities in the office visit setting, at the baseline moment, and 6 months after the intervention, all by a single external observer. RESULTS: The overall baseline compliance level was 8.1% (95% confidence interval [CI], 6.2-10.1), and the healthcare workers of the intervention group increased their hand hygiene compliance level by 21.6% (95% CI, 13.83-28.48) compared with the control group. CONCLUSIONS: This study has demonstrated that hand hygiene compliance in primary healthcare workers can be improved with a multimodal hand hygiene improvement strategy.

[Strategy for implementing and assessing a health care risk management unit in a primary care area]. / Estrategia de implantación y evaluación de una unidad funcional de gestión de riesgos sanitarios en un área de atención primaria.

OBJECTIVE: To describe the setting up of a clinical risk management unit (CRMU) within primary care management, as well as the aims of the project, its implementation phases and the assessment of the results after one year of experience. METHODS: A safety plan was prepared, based on the European Excellence Model (EFQM), to establish a strategic working framework. The plan included 38 proposed actions, associated with criteria elements and 26 indicators to evaluate the selected criteria. RESULTS: A total of 82% of the anticipated actions were implemented in 2007, which included, actions related to teaching and training (15 activities with 237 trainees), spreading of information associated with patient safety, incident analysis (14) and the introduction of specific safe practices (12). Four of those were considered as "generalisable" safe practices and were spread to the rest of the CRMUs in the Autonomous Region of Madrid. The CRMUs have introduced and monitored three processes related to patient safety, participated in a formal programme on the polymedicated elderly, with good results in cover and quality of the indicators. A primary care team (PCT) from the area took part in the first study carried out in Spain on adverse effects in primary care (APEAS Study). CONCLUSIONS: The CRMU can give impetus to strategic lines of safety. The preparation of a strategy defining specific aims has helped in the introduction of patient safety activities and along with the proposed indicators enables the impact of the intervention to be assessed.

Evaluación del cumplimiento de higiene de las manos en un área de atención primaria de Madrid / Evaluation of hand hygiene compliance in a Primary Health care area of Madrid

Introducción La higiene de las manos (HM) es la medida más eficiente para la prevención de infecciones nosocomiales. Nuestro estudio pretende estimar su cumplimiento en atención primaria. Métodos Estudio transversal en el que se ha recogido información sociodemográfica de 198 profesionales. Se evaluó el cumplimiento de HM según los criterios de la Organización Mundial de la Salud. Resultados El cumplimiento de HM fue del 8,1% (intervalo de confianza al 95%: 6,2–10,1). La experiencia laboral de más de 20 años se asoció significativamente a muy bajos niveles de cumplimiento. Conclusión La atención primaria presenta un cumplimiento de HM excesivamente bajo. Es necesario desarrollar programas formativos que aumenten el cumplimiento así como facilitar el acceso a las soluciones hidroalcohólicas (AU)

Introduction Hand hygiene is the most effective measure for preventing infections related to healthcare. This study aims to evaluate the Hand hygiene compliance in Primary Health Care. Methods A cross-sectional study was carried out, collecting socio-demographic data and the hand hygiene compliance from 198 Primary Health Care workers. Their hand hygiene compliance was evaluated according to WHO criteria. Results The level of hand hygiene compliance was 8.1% (95% CI 6.2–10.1). Employment experience of over 20 years was significantly associated with low levels of compliance .Conclusion Primary Health Care workers have a low hand hygiene compliance. Training programs need to be introduced to increase compliance and facilitate access to hydro-alcoholic solutions (AU)

Estrategia de implantación y evaluación de una unidad funcional de gestión de riesgos sanitarios en un área de atención primaria / Strategy for implementing and assessing a health care risk management unit in a primary care area

Objetivo: Describir la puesta en funcionamiento de una unidad funcional de gestión de riesgos sanitarios (UFGRS) en una gerencia de atención primaria, los objetivos del proyecto, las fases para su implantación y la evaluación de resultados tras un año de experiencia. Métodos: Para establecer un marco estratégico de trabajo se elaboró un plan de seguridad según el modelo europeo de excelencia EFQM. El plan incluyó 38 acciones propuestas, relacionadas con los criterios agentes y 26 indicadores para evaluar los criterios resultados. Resultados: En 2007, se implantó el 82% de las acciones previstas. Destacan las acciones relacionadas con docencia y formación (15 actividades con 237 discentes), la difusión de información relacionada con la seguridad del paciente, el análisis de incidentes (14) y la implantación de prácticas seguras específicas (12); 4 de ellas se consideraron como prácticas seguras generalizables y difundidas a las demás UFGRS de la Comunidad de Madrid. La UFGRS implantó y monitorizó 3 procesos relacionados con la seguridad del paciente y ha participado en un programa institucional del anciano polimedicado con buenos resultados en cobertura y calidad de los indicadores. Un equipo de atención primaria (EAP)del área participó en el primer estudio realizado en España sobre efectos adversos en atención primaria (estudio APEAS).Conclusiones: La UFGRS puede impulsar las líneas estratégicas de seguridad. La elaboración de una estrategia que defina objetivos concretos ha facilitado la implantación de actuaciones en seguridad del paciente y, junto a la propuesta de indicadores, permite evaluar el impacto de la intervención (AU)

Objective: To describe the setting up of a clinical risk management unit (CRMU) within primary care management, as well as the aims of the project, its implementation phases and the assessment of the results after one year of experience. Methods: A safety plan was prepared, based on the European Excellence Model (EFQM), to establish a strategic working framework. The plan included 38 proposed actions, associated with criteria elements and 26 indicators to evaluate the selected criteria. Results: A total of 82% of the anticipated actions were implemented in 2007, which included, actions related to teaching and training (15 activities with 237 trainees), spreading of information associated with patient safety, incident analysis (14) and the introduction of specific safe practices (12). Four of those were considered as "generalizable" safe practices and were spread to the rest of the CRMUs in the Autonomous Region of Madrid. The CRMUs have introduced and monitored three processes related to patient safety, participated in a formal programme on the polymedicated elderly, with good results in cover and quality of the indicators. A primary care team (PCT) from the area took part in the first study carried out in Spain on adverse effects in primary care (APEAS Study).Conclusions: The CRMU can give impetus to strategic lines of safety. The preparation of a strategy defining specific aims has helped in the introduction of patient safety activities and along with the proposed indicators enables the impact of the intervention to be assessed (AU)

Mejora de la seguridad y evaluación de los resultados del proceso de anticoagulación oral implantado en un área de atención primaria / No disponible

Objetivo: Describir la mejora de la seguridad del proceso de atención a pacientes con tratamiento de anticoagulación oral (TAO), implantadoen el Área 4 de Atención Primaria (AP) de Madrid, y evaluar los resultados sobre el control y el seguimiento de dichos pacientes después de 1 año de su implantación.Material y método: El trabajo se articula como proyecto de mejora en 3 fases: a) análisis de debilidades, amenazas, fortalezas y oportunidades(DAFO) tras 1 año de implantación del proceso; b) aplicación de la metodología análisis modal de fallos y efectos (AMFE), y c) evaluación de la implantación, el control y el seguimiento de los pacientescon TAO. La obtención de los datos de los pacientes se realizó a través de una explotación específica de los protocolos de seguimiento TAO de la historia clínica informatizada (HCI) OMI-AP. Se incluyó a todos los pacientes anticoagulados seguidos en AP en elaño 2006, con registro en el protocolo específico TAO informatizado. Resultados: La aplicación de la metodología AMFE, bastante novedosaen AP, ha supuesto identificar los fallos críticos priorizados por el índice de priorización del riesgo (IPR); la puntuación del IPR oscilóentre 8 y 343. Igualmente el AMFE nos ha servido para la introducción de acciones de mejora y la elaboración de los indicadores que nos sirven para monitorizar todo el proceso. Los resultados de la primera evaluación indican que el programa está implantado en el 100% de los equipos. El número de pacientes incluidos en el servicioen 2006 fue de 3.013, lo que supone una cobertura del 59,8%. En cuanto al sexo, el 54,2% de los pacientes seguidos (1.633) son mujeres, el 43% (1.305) son varones y hay un 2,5% (75) no registrado. La media de edad es de 75 años. En cuanto a las indicaciones, fibrilación auricular/arritmias cardíacas es la primera causa conun 61% del total. El valor medio de INR ha sido 2,5. La media de determinaciones por paciente: 12,8. Los valores de INR en rango terapéutico son 20.581 (53%) y en rango ajustado a + 0,2 (posible error del coagulómetro) los valores aumentan hasta el 66%. El porcentajede días que permanecen los valores en rango ha sido del68%, y si lo ajustamos al + 0,2%, ascienden al 79% de los días. Solamente encontramos a 13 pacientes con efectos adversos. Conclusiones: La aplicación del AMFE ha supuesto una mejora importantede todo el proceso, fundamentalmente desde el punto de vista de la seguridad, así como la elaboración de unos indicadores de seguimiento.Este estudio aporta resultados sobre el seguimiento de todos los pacientes con TAO, sin necesidad de muestreo, después de 1 año de su implantación, que nos revelan en general su buen control clínico y la aceptación de los profesionales en la realización del nuevo servicio

Objective: To describe improvements in the safety of the management of patients under oral anticoagulation therapy (OAT) implemented in Primary Care Area 4 of Madrid, Spain, and evaluate the results of monitoring of these patients 1-year after implementation.Material and method: The project was developed in three phases: a) Analysis of strengths, weaknesses, opportunities and threats (SWOT) 1 year after implementation of the program; b) Applicationof a failure modes and effects analysis (FMEA), and c) Evaluation of the implementation, monitoring and follow-up of patients receiving OAT. Data were gathered through exportation of the OAT follow-up protocols of the computerized medical records of the computerizedmedical office for primary care (Oficina Médica Informatizada para Atención Primaria [OMI-AP]) program.Results: Application of the FMEA methodology, which is fairly novel in primary care, identified the critical failures prioritized by the Risk Prioritization Number (RPN); the RPN ranged from 8 to 343. FMEA was also useful for the introduction of improvementinterventions and the design of indicators to be used in monitoring the entire process. The results of the first evaluation indicate that the program was implanted in 100% of the teams. The number of patients included in the service in 2006 was 3,013, representing a coverage of 59.8%. A total of 54.2% (1,633) of the patients followed-up were women, 43% (1,305) were menand 2.5% (75) were not registered. The mean age was 75 years. The main indication for OAT was atrial fibrillation/cardiac arrhythmia, accounting for 61% of the total. The mean internationalnormalized ratio (INR) was 2.5. The mean number of determinations per patient was 12.8. There were 20,581 (53%) INR values in the therapeutic range and in the range adjusted to + 0.2 (possible error of the coagulometer), these values increasedto 66%. The percentage of days in which values remained in the range was 68% and when adjusted to + 0.2%, this percentage reached 79% of the days. Only 13 patients experienced adverse effects. Conclusions: Application of FMEA methodology substantially improvedthe entire process, especially safety and the design of follow-up indicators. The present study reports the results on the follow-up of all patients with OAT, without the need for sampling, 1 year after implementation. In general, these results show good clinical management and health professionals’ acceptance of carrying out the new service

Implantación y evaluación informática de un programa de mejora de la calidad asistencial en el Área 4 de Atención Primaria de Madrid / Implementation and computerized evaluation of a healthcare quality program in Primary Care Area 4 in Madrid

Objetivo: Describir el procedimiento automatizado y los resultados de la evaluación de criterios de calidad asistencial basados en la evidencia científica del total de pacientes en el Área 4 de Atención Primaria de Madrid. Métodos: El Programa de Calidad Asistencial del Área recoge 5 criterios priorizados con un total de 22 indicadores: seguimiento y control de la hipertensión arterial; control de hemoglobina glucosilada en diabéticos; prevención secundaria de cardiopatía isquémica; prevención con antiagregantes en patologías de alto riesgo cardiovascular, y tratamiento con inhibidores de la enzima de conversión de la angiotensina en pacientes con insuficiencia cardíaca. Para su evaluación, se ha desarrollado una herramienta basada en sentencias de lenguaje estructurado de consulta (SQL) que permite obtener resultados sobre el total de la población del Área, sin realizar muestreos, a través de los datos recogidos en la historia clínica informatizada (HCI). Resultados: Corresponden a la evaluación de diciembre de 2005. Se evaluaron 89.372 pacientes (69.843 hipertensos, 24.142 diabéticos, 10.086 diagnosticados de cardiopatía isquémica, 30.440 con patologías de alto riesgo cardiovascular y 2.517 presentaban insuficiencia cardíaca). La información completa se distribuyó a todos los profesionales en una hoja de cálculo Excel con los datos de todos sus pacientes. Conclusiones: La implantación de un programa de calidad asistencial permite promover y evaluar intervenciones con impacto reconocido en la salud de la población. La utilización de la HCI permite obtener datos de toda la población de referencia, con un coste mínimo, sin necesidad de muestreo y de forma sencilla y rápida

Objectives: To describe to the automated procedure and the results of an evaluation of evidence-based healthcare quality criteria in the total number of patients in Primary Care Area 4 in Madrid. Methods: The Healthcare Quality Program of Area 4 gathers five prioritized criteria with a total of 22 indicators: follow-up and control of hypertension, control of glycosylated hemoglobin in diabetics, secondary prevention of coronary heart disease, prevention with antiplatelet therapy in diseases with high cardiovascular risk, and angiotensin-converting-enzyme inhibitors in the treatment of patients with heart failure. To evaluate the criteria, we developed a tool based on structured query language (SQL) that allowed us to obtain results on the entire population of the Area (581,000 persons), without the need for sampling, through the data gathered in the computerized clinical histories. Results: The results correspond to the evaluation performed in December 2005. A total of 89,372 patients were evaluated (69,843 with hypertension, 24,142 with diabetes, 10,086 with a diagnosis of coronary heart disease, 30,440 with diseases with high cardiovascular risk, and 2,517 with heart failure). The complete information was distributed to all the health professionals in an Excel spreadsheet with data on all their patients. Conclusions: The implementation of a healthcare quality program allows interventions with an established impact on the health of the population to be promoted and evaluated. The use of the computerized clinical history allows data on the entire population in the catchment area to be obtained rapidly and simply, with minimal cost, and without the need for sampling

Trabajar con método científico. A propósito de una experiencia / Working with the scientific method

Para mejorar la calidad de la prestación de los cuidados enfermeros, la Dirección de Enfermería del Área 7 de Madrid elaboró un plan de trabajo basado, fundamentalmente, en la implantación progresiva del método científico en el trabajo enfermero habitual. Este estudio (descriptivo transversal) mide el grado de implantación de la metodología tras 18 meses de desarrollo del plan y compara los resultados con los obtenidos en los seis primeros meses. La Dirección de Enfermería había planteado alcanzar, a los 18 meses, un 50 por ciento de cumplimentación completa del proceso enfermero de los usuarios inmovilizados y terminales. El objetivo se ha cumplido en cuanto a la valoración por patrones y registro del diagnóstico enfermero. Hay que mejorar en la cumplimentación del plan de cuidados, así como en el registro de la evaluación. (AU)

Trabajar con método científico / Working with the scientific method

Para mejorar la calidad de la prestación de los cuidados enfermeros, la Dirección de Enfermería del Área 7 de Madrid elaboró un plan de trabajo basado, fundamentalmente, en la implantación progresiva del método científico en el trabajo enfermero habitual. Este estudio (descriptivo transversal) mide el grado de implantación de la metodología tras 18 meses de desarrollo del plan y compara los resultados con los obtenidos en los seis primeros meses. La Dirección de Enfermería había planteado alcanzar, a los 18 meses, un 50 por ciento de cumplimentación completa del proceso enfermero de los usuarios inmovilizados y terminales. El objetivo se ha cumplido en cuanto a la valoración por patrones y registro del diagnóstico enfermero. Hay que mejorar en la cumplimentación del plan de cuidados, así como en el registro de la evaluación (AU)