Adverse events in the global healthcare practice of an Occupational Mutual Insurance Company in Spain

BACKGROUND

Patient safety is currently a main issue in healthcare practice. Adverse events (AEs) management is a key instrument for the application of strategies to prevent harm to patients.

OBJECTIVE

To analyze the type, severity and preventability, according to validated scales, of AEs occurring annually in the healthcare practice of an Occupational Mutual Insurance Company in order to implement action plans to improve patient safety.

METHODS

We analyzed the reported AEs in an Incident Reporting System and AEs detected in the Audit program of clinical records as a result of treating injured or ill workers in our 88 ambulatory care centers.

RESULTS

We detected 28 AEs in the clinical records (CR), representing 0.05 AE/CR, with maximum values in the COM sample (26 AEs, 0.11) and much lower in INT (1 AEs, 0.02) and MIN (1 AE, 0.02). The most frequent AE type was procedure-related, followed by infection and care. AEs of severity level D (11 cases) and E (9 cases) predominated, while level F was also detected (6 cases). Intermediate values in preventability (3 and 4) predominated, 61.5% were preventable. With the Incident Reporting System, 27 AEs were identified, predominated by procedural type. Most reported AE severities was in levels E (10 cases) and C (8 cases), 89% were preventable.

CONCLUSION

Our company detects AEs via the Incident Reporting System and annual Audit program of clinical records, both of which are complementary, and may result in the implementation of more effective Patient Safety measures.

Health protection among own account and platform workers during COVID19 in Chile. The PWR project

Background

In the last decades, non-standard employment has grown globally. Especially for own account workers (OAW), this implies the self-management of economic, health and other work-related risks. In the context of COVID19, this management was stressed by lockdowns and the novel health risks imposed by an unknown and highly contagious virus, demanding the incorporation of new knowledge and preventive actions. As part of a six-country multiple case qualitative study on non-standard workers (NSW), we explore their experiences and strategies deployed to protect their health while continuing to work.

Methods

We performed 40 in-depth interviews to NSWs between October 2020 and February 2021, identified through the PWR online-survey and selected through an intentional sampling strategy according to levels of precarity (high-low), gender (male/female) and age (18-39/40-55). Interviews were analysed through abductive thematic analysis.

Results

We observed a significant transfer to platform, Uber-like jobs in the delivery of goods during lockdown (n = 7). In the absence of institutional prevention programs and provision of protective equipment, OAWs (n = 13) refer the self-provision of COVID19 prevention to protect themselves and their families while continuing to work, deploying a series of strategies amidst limited understanding of both mode of transmission of the virus and actual effective preventive measures. This had serious consequences for them and their families, expressed in anguish, sense of lack of control, fear, and fragility in the face of a major health risk given their constant potential exposure to the virus, leading to both physical and mental health problems, as well as COVID19 infection.

Conclusions

The substantial growth worldwide of gig delivery work during lockdowns magnified a pressing public health problem, critically requiring social security for gig and OAWs and the development of more equitable and accessible occupational health for all.

Key messages

• Substantial growth worldwide of gig delivery work during lockdowns magnified a pressing public health problem.

• Social security for gig and OAWs are critically required as well as the development of more equitable and accessible occupational health for all.

Risk Management in the Ambulatory Care Process in a Mutual Benefit Association Covering Work-Related Accidents and Diseases: Applying Modified Failure Mode and Effect Analysis (FMEA) Methodology

AIM

To assess the impact of different forms of use of failure mode and effect analysis methodology for risk prioritization in the ambulatory care process in a mutual benefit association covering work-related accidents and diseases.

METHODS

The study is based on a previously drafted and individually prioritized risk map by a multidisciplinary team made up of patient safety committee members from health care centers and clinics in a mutual benefit association covering work-related accidents and diseases. The professionals mainly carry out their work in the field of management (individual manager group (IMG)). A group formed by clinicians subsequently completed 2 prioritizations: one based on the individual opinions of each of the members (individual clinical group (ICG)) and another in a consensual way (consensual clinical group (CCG)) as recommended by failure mode and effect analysis methodology. The risk prioritization was compared in the 3 groups (IMG, ICG, and CCG).

RESULTS

The risk prioritization by the IMG defines 7 extreme risks (risk prioritization ≥ 275). When the clinical group prioritizes them in an individual way (ICG), there is no extreme risk, whereas when it does so in a consensual way (CCG), there are 21 extreme risks. With respect to the coincidences of existing causes between the 3 groups, it is noted that the "risk of falls" is rated by both the clinical and the manager group but prioritized differently. On the other hand, the ICG and CCG coincide in that pressure on health care services can contribute to carrying out incomplete anamnesis. They also both consider that internal and external waiting lists and holiday periods can cause a delay in the starting of rehabilitation. The IMG and the CCG show similarity in the risk assessment of overprescribing medication and that multiple computer sessions are initiated. Finally, the IMG and the ICG coincide in the "lack of delivery of the medication leaflet".

CONCLUSIONS

The point of view of the clinicians is important in the risk prioritization of the ambulatory health care process. The difference in the risk prioritization between the clinical group at individual level and after consensus is remarkable.

Frequency of outpatient care adverse events in an occupational mutual insurance company in Spain

BACKGROUND

Occupational mutual insurance companies (OMICs), in collaboration with the Spanish Social Security System, provide healthcare and manage the economic benefits for the workers in Spain. They have ambulatory care centers that attend outpatient trauma pathology, although most of the studies published have focused on surgical and hospital activity. The aim of this study was to detect adverse events (AEs) in outpatient trauma care in the context of an OMIC.

METHODS

A cohort study designed to identify harmful safety incidents (adverse events, AEs) in 2017 was conducted. A random sample of 313 medical records among patients who were visited more than 3 medical and nursing attendances during their outpatient process. The AEs detected were classified according to category, severity and preventability.

RESULTS

We identified 48 AEs (15.3% of medical records, 95% CI 11.3-19.3), most of them procedure-related, while 27 (56.2%) were preventable and 46 mild (95.8%).

CONCLUSIONS

The AEs identified are double than those found in primary care general consultations in Spain and are close to the lower range of studies on surgical AEs in traumatology and orthopedics. Preventable AEs were within expected limits. Over half of AEs are preventable, within that group, the mild AEs have an increased rate of preventability. These results highlight the relevance of research of patient safety in the outpatient care of trauma and orthopaedic procedures in an OMIC for patient safety and contribute to introduce improvements in outpatient care.

Drug eruption due to bupropion, a case report

Introduction

We present a clinical case of eruption caused by the use of bupropion. Bupropion is known to cause hypersensitivity reactions.

Case report

We report the case of a 48-year-old female who was diagnosed of depressive disorder. She went to emergency because a few days after prescribing bupropion (150 mg/24 h) scaly skin eruptions were found distributed along the skin. In the present case, after its introduction, bupropion was found to be a probable etiological agent. The patient was successfully treated with corticosteroids. Because of that, bupropion dosage was stopped and replaced with fluoxetine. No remissions and exacerbations were noticed in a month's follow up.

Discussion

In this case report, we present a patient with an eruption related to bupropion. The aetiological spectrum of eruption include drugs, infectious agents and food additives. Drugs attributing eruption include nonsteroidal anti-inflammatory drugs, antibiotics, and anti-epileptic drugs, antidepressive medication amongst others.

Conclusions

No specific diagnostic criterion exists for eruption and the diagnosis is purely based on clinical presentation. Diagnostic features, which suggest eruption, are the acute onset (or recurrent nature) and skin lesions.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

What should we know about precarious employment and health in 2025? Framing the agenda for the next decade of research

The generalization of flexible labour markets, the declining influence of unions and the degradation of social protection has led to the emergence of new forms of employment at the expense of the Standard Employment Relationship, as well as a considerable amount of research across social and scientific disciplines. Years ago we suggested the urgent need to disentangle the consequences of new types of employment for the health and well-being of workers, contending that the study of precarious employment and health is in its infancy. Today, research challenges include clearer, more precise definitions of the original concepts, a more detailed understanding of the pathways and mechanisms through which precarious employment harms worker health, stronger information systems for monitoring the problem and a complex systems approach to employment conditions and health research. All of these must be guided by the theoretical and policy debates linking precarious employment and health, and be geared towards developing better tools for the design, implementation and evaluation of policies intended to minimize precariousness in the labour market and its effects on public health and health inequalities. Our aim in this paper is to outline an agenda for the next decade of research on precarious employment and health, establishing a compelling programme that expands our understanding of complex causes and links.

Local verification between the hematological analyzers Sysmex XN-series and XE-5000

INTRODUCTION

The aim of this study was to perform a verification of the hematology analyzer Sysmex XN-2000 by comparing with the previous XE-5000. This study assessed the precision and carryover on the XN-2000 and the systematic error between the both counters according to desirable biological variability criterion and a flag comparison study.

METHODS

Within-run precision and between-batch precision were measured according to the ICSH guidelines. A comparative study was performed analyzing two hundred and six samples of peripheral blood from patients. The statistical study was conducted using the Passing-Bablok and Bland-Altman analyses. The leucocyte flag comparison was made by measuring the efficiency rate.

RESULTS

Between-batch precision was lower than that recommended by the biological variability criterion and manufacturer specifications. The comparison gave nonagreement results for neutrophil and basophil counts according to the criterion of biological variability. Erythroblasts and immature granulocytes showed nonagreement, but there is no available biological variation database for these parameters to compare with. Nevertheless, excellent absolute agreement was found for red blood cell parameters, and for platelet, lymphocyte, monocyte, and eosinophil counts.

CONCLUSIONS

The global results obtained for the precision, comparability, and efficiency provide a satisfactory integration of the XN-2000 in the core laboratory routine and accomplish an optimal reliability.

Pilot study to introduce a notification card for partner notification of sexually transmitted infections in Catalonia, Spain, June 2010 to June 2011

We conducted a cross-sectional study in 10 primary care centres in Catalonia, to determine applicability, acceptability and effectiveness of partner notification cards used by patients diagnosed of a sexually transmitted infection (STI) and to characterise these and their sexual partners. Statutorily notifiable STIs included Chlamydia infection, gonorrhoea, syphilis, human immunodeficiency virus (HIV) infection or other STIs as deemed necessary by the treating physician. Between June 2010 and June 2011, 219 index cases were enrolled, of whom 130 were men (59.4%), 71 of them men who have sex with men (54.6%). Chlamydia infection (41.1%), gonorrhoea (17.8%) and syphilis (16.0%) were the STIs most frequently diagnosed. HIV infection accounted for 4% of cases. A total of 687 sexual partners were reported, and 300 of these were traceable through the notification card (45.7%). Those who did not report traceable contacts were older (mean age: 34 years versus 31 years, p=0.03). The main reason for not distributing the card was anonymous sexual intercourse (38%). Patient referral notification cards can reach a high percentage of sexual partners at risk. However, only few notified sexual partners attended participating health centres. Internet-based partner notification may be considered in order to reach those partners not otherwise traceable.

Lymphogranuloma venereum: a hidden emerging problem, Barcelona, 2011

From the beginning of 2007 until the end of 2011, 146 cases of lymphogranuloma venereum (LGV) were notified to the Barcelona Public Health Agency. Some 49% of them were diagnosed and reported in 2011, mainly in men who have sex with men. Almost half of them, 32 cases, were reported between July and September. This cluster represents the largest since 2004. This article presents the ongoing outbreak of LGV in Barcelona.

Lymphogranuloma venereum: a hidden emerging problem, Barcelona, 2011

From the beginning of 2007 until the end of 2011, 146 cases of lymphogranuloma venereum (LGV) were notified to the Barcelona Public Health Agency. Some 49% of them were diagnosed and reported in 2011, mainly in men who have sex with men. Almost half of them, 32 cases, were reported between July and September. This cluster represents the largest since 2004. This article presents the ongoing outbreak of LGV in Barcelona.

Cavernositis following intracavernous injection of vasoactive drugs

Intracavernous injection is one of the most common treatments of erectile dysfunction. Infectious complications are rare, but hazardous. We report the case of a 44-year-old to stress the importance of patient supervision and drug prescription.

Virtual automation

Total laboratory automation (TLA) can be substituted in mid-size laboratories by a computer sample workflow control (virtual automation). Such a solution has been implemented in our laboratory using PSM, software developed in cooperation with Roche Diagnostics (Barcelona, Spain), to this purpose. This software is connected to the online analyzers and to the laboratory information system and is able to control and direct the samples working as an intermediate station. The only difference with TLA is the replacement of transport belts by personnel of the laboratory. The implementation of this virtual automation system has allowed us the achievement of the main advantages of TLA: workload increase (64%) with reduction in the cost per test (43%), significant reduction in the number of biochemistry primary tubes (from 8 to 2), less aliquoting (from 600 to 100 samples/day), automation of functional testing, drastic reduction of preanalytical errors (from 11.7 to 0.4% of the tubes) and better total response time for both inpatients (from up to 48 hours to up to 4 hours) and outpatients (from up to 10 days to up to 48 hours). As an additional advantage, virtual automation could be implemented without hardware investment and significant headcount reduction (15% in our lab).

Type-1 and type-2 cytokines in human decidual tissue and trophoblasts from normal and abnormal pregnancies detected by reverse transcriptase polymerase chain reaction (RT-PCR)

PROBLEM

Cytokine expression at the maternal fetal interface has been well documented in rodents, but data in the human are scanty and controversial.

METHOD OF STUDY

We examined cytokine expression of human decidua and trophoblasts by semiquantitative visual grading of reverse transcriptase polymerase chain reaction (RT-PCR) products in five groups of patients: ten patients with uncomplicated term pregnancies undergoing elective cesarean section (Group 1); ten women having normal pregnancies at term and vaginal delivery (Group 2); ten patients having intrauterine growth-retarded infants of unknown cause after a spontaneous vaginal delivery at term (Group 3); ten childless women having their first, first-trimester spontaneous abortion (Group 4); and ten childless women with a history of one or more previous first-trimester spontaneous abortions and having a new miscarriage (Group 5).

RESULTS

Results favoring the T-helper 1 (Th1)/T-helper 2 (Th2) model during pregnancy were: significantly higher expression of interferon gamma (IFN-gamma) in trophoblast samples from Group 3 versus 2 and in decidual tissue from Group 5 versus 4; stronger positivity of interleukin (IL)-10 in decidual tissue samples from Group 1 versus Groups 2 and 5; and higher expression levels of tumor necrosis factor-beta (TNF)-beta by the trophoblast in Group 5 versus 1. Against the Th1/Th2 paradigm were the following findings: the significantly increased expression of IFN-gamma by decidual or trophoblast samples in Groups 1 versus 2, 2 versus 3, and 1 versus 5; and the significantly higher expression of TNF-alpha in decidual samples from patients in Group 1 (but also Group 4) as compared with Group 5. IL-2 mRNA and IL-4 mRNA could not be detected.

CONCLUSIONS

Overall, our findings suggest that there is a balance between type-1 and type-2 cytokines during pregnancy, which is mainly characterized by the expression of IFN-gamma (a type-1 cytokine) and IL-10 (a type-2 cytokine) at the maternal fetal interface.

[Acceptability of auto-injection of vasoactive drugs in the treatment of erectile dysfunction]

OBJECTIVES

To study the utility of the PenInject 2.25 (SHL Medical AB), an instrument for intracavernous auto-injection of vasoactive drugs.

METHODS

61 males, aged 30-70 years, with erectile dysfunction were studied. The study comprised two groups: group A consisted of 26 patients previously treated with intracavernous injections using a syringe that were started on treatment with the self-injector, and group B consisted of 35 previously untreated patients that started treatment directly with the self-injector. Different data and questions on the facility of use and acceptance of the instrument were analyzed. Data evaluation were plotted on visual analog scales of 10 cm. A score of 5 or more showed good results and less than 5 was considered unfavorable.

RESULTS

The positive aspects were facility of use, comfort, design of the self-injector, which scored higher than 7. The negative aspects were pain, fear, discomfort intensity, which scored below 4.

CONCLUSIONS

The use of the PenInject self-injector in this group of patients improved the acceptability of intracavernous therapy for erectile dysfunction in comparison to the classical syringe.

The role of trauma and dissociation in cognitive-behavioral psychotherapy outcome and maintenance for panic disorder with agoraphobia

The relationship between traumatic experiences and dissociation with pretreatment psychopathology and rates of recovery, relapse and maintenance for patients receiving cognitive-behavioral treatments for panic disorder with agoraphobia (PDA) were investigated. One-hundred and forty-seven subjects who met DSM-III criteria for agoraphobia with panic attacks and who completed participation in one of two previously conducted treatment outcome studies were mailed packets containing measures to assess history of trauma, victimization and dissociation. Eighty-nine of these were returned and completed sufficiently to be included in the present study. It was hypothesized that a variety of trauma-related variables (e.g. history of traumatic experience, type of trauma, age at which the trauma first occurred, perceived responsibility, social supports available, self-perceived severity, level of violence, and whether or not the traumatic event was followed by self-injurious or suicidal thoughts and/or behaviors) and dissociative symptomatology would be predictive of (1) greater psychopathology at pretreatment, (2) poorer treatment response and (3) higher relapse rates and poorer maintenance over a 1 year longitudinal follow-up. These hypotheses were supported by the findings and the theoretical, empirical and clinical implications are discussed.

The effect of hormone replacement therapy on bone mass in patients with ovarian failure due to bone marrow transplantation

BACKGROUND

Long permanent remissions in malignant hematopoietic disorders can often be achieved by autologous bone marrow transplantation (ABMT) or by allogenic bone marrow transplantation (BMT). Previous studies have shown that such therapies may induce osteoporosis due to iatrogenic ovarian failure. The administration of hormone replacement therapy (HRT) in these women could prevent the adverse effects of long-term ovarian failure without remarkable side effects. The aim of this study was to evaluate how the bone mass is affected by HRT in patients undergoing ABMT or BMT adjusting the results for age, weight, and height.

SUBJECTS AND METHODS

Thirteen women with previous ABMT/BMT were treated with a standard dose (0.625 mg/day) of conjugated equine estrogen (CEE) or with 50 micrograms/day of 17-beta-estradiol in transdermal therapeutic systems (TTS) plus 5 mg/day of medroxyprogesterone acetate sequentially added to the last 12 days of estrogen therapy. Bone mass was measured prior to and 12 months following HRT. Blood samples were collected before therapy and during the 6th and 12th treatment months.

RESULTS

The mean time elapsed between bone transplantation and HRT initiation was 13.0 months (range 3-26 months). Before treatment nine patients were osteopenic and after HRT bone mass increased in all cases. Following ABMT/BMT, hepatic hyperenzymemia was detected in three patients. After 6 and 12 months of treatment no significant changes were observed in hepatic enzymes.

CONCLUSION

Although hepatic hyperenzymemia is commonly considered as a contraindication for HRT, our results suggest that HRT is safe for these patients and that such therapy should be initiated after transplantation in women to prevent adverse effects of long-term ovarian failure.

Oral surgery in anticoagulated patients without reducing the dose of oral anticoagulant: a prospective randomized study

PURPOSE

This study assessed the risk associated with several schedules of perioperative treatment with coumadin in anticoagulated patients who underwent oral surgery.

PATIENTS AND METHODS

A prospective, randomized study compared bleeding complications with six perioperative schedules in 92 patients chronically treated with acenocoumarol. In three of the perioperative schedules, the dose was reduced before surgery and calcium heparin was added. In the other three, oral anticoagulation was not modified and heparin was not used. The groups also differed regarding the antifibrinolytic agents used and the postoperative measures applied.

RESULTS

Those schedules in which the oral anticoagulation was not modified preoperatively and an antifibrinolytic agent was applied locally both during and after surgery were not associated with a significantly higher odds ratio of bleeding complications than those in whom oral anticoagulation was reduced and calcium heparin was added preoperatively.

CONCLUSIONS

In orally anticoagulated patients who undergo oral surgery, schedules that maintain the oral anticoagulant regimen and use local tranexamic acid as an antifibrinolytic agent postoperatively for 2 days are safe, simple, and less troublesome.

Maternal brain death during pregnancy

A case of a 36-year-old woman diagnosed brain dead secondary to pneumococcal meningitis at 27 weeks of gestation is presented. In spite of aggressive therapy, supportive intensive care was possible for only 36 h. Signs of fetal distress appeared and a cesarean section was performed. The complexity of supportive care and its ethical implications are discussed.

Is MRI helpful in evaluating the response of cervical cancer to neoadjuvant chemotherapy?

BACKGROUND

To assess the potential role of magnetic resonance imaging (MRI) in evaluating the response of cervical tumor to neoadjuvant chemotherapy.

METHODS

We studied 14 patients with locally advanced carcinoma of the cervix. MRI was performed before and after each cycle. All patients underwent laparotomy four weeks after the last cycle. MR images after chemotherapy were compared with surgical-pathologic findings.

RESULTS

Related to parametrial state after chemotherapy, surgical examination correlated with MRI in nine patients (nine true negative). In three cases parametrial invasion was over-estimated (three false-positive) and in two it was underestimated, so that tumor resection was not possible once laparotomy was performed (two false-negative). MRI estimation of tumor size was confirmed at pathologic examination in only eight patients, whilst it was over-estimated in the other four ones.

CONCLUSIONS

These initial results suggest that MRI could not be as precise for cervix cancer staging and evaluation of response to chemotherapy as has recently been postulated. This is especially important since a false negative result may induce the surgeon to perform laparotomy in error in cases of unresectable tumors.

Muscular structural changes following fadenoperation

The authors describe the macroscopic, histological, and ultrastructural findings observed in an experimental animal model of the fadenoperation . Grossly, muscular fibrosis and musculo-scleral adhesions were well established after the second postoperative month. Histologic findings demonstrated the development of a granulomatous, foreign body reaction around the musculo-scleral fixation suture, collagenization of the muscle tissue from the first postoperative month and degenerative phenomena in the muscle fibers. Electron transmission microscopic study showed atrophy and angulation with distortion of the myofibrillar matrix, along with alteration of the Z bands of muscle fibers, mitochondrial alteration, and dilatation of the sarcotubular system. All these experimental findings suggest the relative irreversible effects of the fadenoperation after the early postoperative period and for the first time, demonstrated that this surgical technique alters the muscle structure.