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Resumen Objetivos Estudiar la distribucion espacio-temporal de los casos de enfermedad neumococica invasora (ENI) por serotipos resistentes a eritromicina y su relacion con el consumo comunitario de macrolidos y la cobertura vacunal infantil. Metodos Se seleccionaron los casos de ENI en mayores de 59 anos residentes en la Comunidad de Madrid (CM) notificados en el periodo de 2007 a 2016. Las variables estudiadas fueron obtenidas de los sistemas de informacion vacunal y de Prestacion Farmaceutica. Se utilizo el punto de corte (concentracion minima inhibitoria de eritromicina > 0,5 mg/L) de la clasificacion de EUCAST para definir los serotipos resistentes a eritromicina. Mediante JointPoint se estimaron las tendencias de las incidencias de casos por serotipos resistentes a eritromicina incluidos en la vacuna trecevalente (STVCN13) y no incluidos (STnoVCN13). La asociacion de esas incidencias con el consumo comunitario de macrolidos y la cobertura vacunal se hizo mediante modelos de Poisson. Para la deteccion de clusteres espacio-temporales se utilizo el estadistico Satscan. Resultados Se identificaron 1.936 casos, de ellos, se detecto que 427 serotipos eran resistentes a la eritromicina. La incidencia de todos los casos por serotipos resistentes fue descendente (AAPC: -5,40%). La incidencia de casos por STVCN13 resistentes a la eritromicina fue descendente con un porcentaje anual del cambio (APC: -13,8) y estuvo asociada inversamente a la cobertura vacunal infantil (IRR 0,641), mientras que la de casos por STnoVCN13 resistentes a eritromicina fue ascendente (APC: 4,5) y no se asocio con la cobertura. Se detecto un cluster por STnoVCN13 y ninguno por STVCN13 tras la inclusion de la trecevalente en el calendario vacunal infantil. Conclusiones El descenso de ENI por STVCN13 resistentes se asocio con el incremento de la cobertura vacunal infantil. La presencia de clusteres de casos por STnoVCN13, en el periodo posterior a la inclusion de la VCN13, indica reemplazo de serotipos. El aumento de los casos por STnoVCN13 resistentes podria estar relacionado por el reemplazo de los serotipos vacunales en la colonizacion nasofaringea, facilitada por el consumo de macrolidos todavia a niveles altos en la CM.

Summary Background The coronavirus disease 2019 pandemic has caused problems with respirator supplies. Re-use may minimize the impact of the shortage, but requires the availability of an efficient and safe decontamination method. Aim To determine whether low-temperature-steam–2%-formaldehyde (LTSF) sterilization is effective, preserves the properties of filtering facepiece (FFP) respirators and allows safe re-use. Methods Fourteen unused FFP2, FFP3 and N95 respirator models were subjected to two cycles of decontamination cycles. After the second cycle, each model was inspected visually and accumulated residual formaldehyde levels were analysed according to EN 14180. After one and two decontamination cycles, the fit factor (FF) of each model was tested, and penetration tests with sodium chloride aerosols were performed on five models. Findings Decontamination physically altered three of the 14 models. All of the residual formaldehyde values were below the permissible threshold. Irregular decreases and increases in FF were observed after each decontamination cycle. In the sodium chloride aerosol penetration test, three models obtained equivalent or superior results to those of the FFP classification with which they were marketed, both at baseline and after one and two cycles of decontamination, and two models had lower filtering capacity. Conclusion One and two decontamination cycles using LTSF did not alter the structure of most (11/14) respirators tested, and did not degrade the fit or filtration capacity of any of the analysed respirators. The residual formaldehyde levels complied with EN 14180. This reprocessing method could be used in times of shortage of personal protective equipment.

Resumen: Objetivo: 1) Determinar la percepción de seguridad que tienen los/las profesionales sanitarios/as y no sanitarios/as en un hospital universitario; 2) describir el clima de seguridad con sus fortalezas y debilidades; y 3) evaluar las dimensiones valoradas negativamente y establecer áreas de mejoras. Método: Estudio transversal y descriptivo realizado en el Hospital Universitario San Juan de Alicante en el que se recogen los resultados de la valoración del nivel de cultura de seguridad utilizando como instrumento de medición la encuesta Hospital Survey on Patient Safety Culture de la Agency for Healthcare Research and Quality adaptada al español. Resultados: La tasa de respuesta fue del 35,36%. El colectivo con mayor participación fue el médico (32,3%), y el servicio más implicado, el de urgencias (9%). El 86,4% tuvo contacto con el paciente. El 50% de los/las trabajadores/as calificó el clima de seguridad entre 6 y 8 puntos. El 82,8% no notificó ningún evento adverso en el último año. Los profesionales con mayor cultura de seguridad fueron los farmacéuticos, y los que tuvieron peor cultura, los celadores. No se identificó ninguna fortaleza de manera global. Hubo dos dimensiones que se comportaron como una debilidad: la 9 (dotación de personal) y la 10 (apoyo de la gerencia a la seguridad del paciente). Conclusiones: La percepción sobre seguridad del paciente es buena, aunque mejorable. No se han identificado fortalezas. Las debilidades identificadas son dotación de personal, apoyo de la gerencia a la seguridad del paciente, cambios de turno y transición entre servicios, y percepción de seguridad. Abstract: Objective: 1) To determine the perception of safety of health professionals and non-health professionals in a university hospital; 2) describe the climate of safety with its strengths and weaknesses; 3) evaluate the negatively valued dimensions and establish areas of improvement. Method: A cross-sectional and descriptive study carried out at the San Juan University Hospital in Alicante, where the results of the assessment of the safety culture level are collected using Hospital Survey On Patient Safety survey of the Agency for Healthcare Research and Quality adapted to Spanish language. Results: The response rate was 35.36%. The group with the greatest participation was the physician (32.3%) and the service most involved, urgencies (9%). 86.4% had contact with the patient. 50% of workers rated the safety climate between 6 and 8 points. 82.8% did not report any adverse events in the last year. The professionals with the greatest security culture were the pharmacists and with the worst culture, the guards. No strength was identified globally. There were two dimensions that behaved like a weakness: 9 (staffing) and 10 (management support for patient safety). Conclusions: The patient's perception of safety is good, although it can be improved. No strengths have been identified. The weaknesses identified are staffing, management support for patient safety, handoffs and transitions, and safety perception.

Resumen Antecedentes y objetivo Durante la pandemia COVID-19 se ha producido un aumento de la demanda de mascarillas por parte de profesionales sanitarios y de la poblacion general. En este contexto, se hace necesario sintetizar las caracteristicas y las indicaciones de uso de los distintos tipos de mascarillas existentes. Material y metodos Se consultaron y recopilaron las diferentes recomendaciones difundidas por instituciones de reconocido prestigio, como la Organizacion Mundial de la Salud, The European Centre for Disease Prevention, The Centre for Evidence-Based Medicine o el Ministerio de Sanidad del Gobierno de Espana. Resultados Las instituciones consultadas aconsejan reservar las mascarillas filtering face piece (FFP) para el personal sanitario, especialmente en la realizacion de procedimientos generadores de aerosoles (PGA) (proteccion minima de FFP2), y plantean posibles sistemas de reutilizacion durante epocas de escasez. Asimismo, se recomienda el uso de mascarillas quirurgicas en profesionales que no realicen PGA y en poblacion sintomatica, existiendo variacion en las indicaciones de uso para poblacion general sana. Conclusion En situaciones de escasez de equipos de proteccion individual por pandemia de COVID-19 se debe establecer una priorizacion y racionalizacion de uso de cada tipo de mascarilla en funcion del usuario y de la actividad a realizar.

(1) Background: The development of effective COVID-19 vaccines has reduced the impact of COVID-19 on the general population. Our study aims to analyze how vaccination modifies the likelihood of death and length of stay in hospitalized patients with COVID-19; (2) Methods: A retrospective cohort study of 1927 hospitalized patients infected with COVID-19 was conducted. Information was gathered on vaccination status, hospitalization episode, and clinical profile of the patients. The effect of vaccination on mortality was analyzed using a multiple logistic regression model, and length of stay was analyzed using linear regression. The performance and fit of the models were evaluated; (3) Results: In hospitalized patients with COVID-19, the risk of dying during admission in vaccinated patients was half that of non-vaccinated (OR: 0.45; CI 95%: 0.25 to 0.84). In patients who were discharged due to improvement, the reduction in hospital stay in vaccinated patients was 3.17 days (CI 95%: 5.88 to 0.47); (4) Conclusions: Patients who, despite having been vaccinated, acquire the infection by SARS-CoV-2, have a significant reduction of the risk of death during admission and a reduction of hospital stay compared with unvaccinated patients.

(1) Background: Adverse events (AE) affect about 1 in 10 hospitalised patients, and almost half are related to surgical care. The aim of this study is to determine the prevalence of AE in operated and non-operated patients in surgical departments in order to determine whether surgical treatment is a risk factor for AE. (2) Methods: A cross-sectional design that included 3123 patients of 34 public hospitals in the Community of Madrid determining the prevalence of AEs in operated and non-operated patients in surgical departments. (3) Results: The prevalence of AE in non-operated patients was 8.7% and in those operated was 15.8%. The frequency of AE was higher in emergency surgery (20.6% vs. 12.4%). The 48.3% of AEs led to an increase in hospital stay, and surgery was involved in 92.4% of cases. The most frequent AEs were related to hospital-acquired infection (42.63%), followed by those related to a procedure (37.72%). In the multivariate analysis, being operated on represented 2.3 times the risk of developing an AE. (4) Conclusions: Surgical sites are particularly vulnerable to AE. Surgical intervention alone is a risk factor for AE, and we must continue to work to improve the safety of both patient care and the working environment of surgical professionals.

The major goals of the study were to describe the invasive pneumococcal disease (IPD) cases due to erythromycin-resistant serotypes and to evaluate the association between these cases and recent macrolide use in individuals aged over 59 years. We selected cases of IPD reported between 2007 and 2016 in persons aged over 59 years living in the Community of Madrid (CM). We followed the European Committee on Antimicrobial Susceptibility Testing (EUCAST). The explanatory variables (age, sex, year of onset of symptoms, clinical presentation, serotypes, vaccination status) were taken from the Mandatory Notification System for Infectious Diseases System and from the Vaccination Information System. The cases were classified as either included in the 13-valent pneumococcal conjugate vaccine (PCV13) or not (nonPCV13). Associations between cases due to erythromycin-resistant serotypes and previous macrolide use (total, long and short-term) were adjusted with a logistic regression multivariate analysis. A total of 1,831 cases were identified, of whom 408 were erythromycin-resistant serotypes. PCV13 cases were associated with previous macrolide use (OR: 5.07), particularly long-acting types (OR: 8.61). NonPCV13 cases were associated with the use of total macrolides (OR: 3.48) and long-acting macrolides (OR: 4.26) suggesting that PCV13 did not reduce the IPD cases in patients with previous use of macrolides. Our results confirmed that previous macrolide consumption was associated with the presence of IPD due to erythromycin-resistant serotypes. The risk was higher with the use of long-term macrolides.

It is important to know the impact of public financing on routine vaccination on compliance with the vaccination regimen. Few studies have been carried out on this topic. The objective of this study was to describe the effect of public financing of pneumococcal vaccine on vaccination coverage and the degree of compliance with the vaccination regimen in the child population of the Community of Madrid (CM).A descriptive observational study was carried out. The study population were children vaccinated in the period of public (2008 and 2010) and private (2012 and 2013) funding. Data source was the vaccination information system. We estimated the coverage of "full inmunization" at 24 months and the coverage of "vaccination on time" of the primary vaccination and the complete schedule. Comparison according to the type of financing was made using the prevalence ratio (PR) and the relative percentage of change. The delay between vaccine doses was calculated at 24 months of age.On-time vaccination coverage was 72% when public financing of the vaccine and 64% when private financing (PR= 1.12). The delay between doses was greater than 10% when funding was private.Public financing of the vaccine improves compliance with the vaccine regimen.Es importante conocer el impacto de la financiación pública de la vacunación sistemática sobre el cumplimiento de la pauta vacunal. Se han realizado pocos estudios sobre este tema. El objetivo de este estudio fue describir el efecto de la financiación pública de la vacuna antineumocócica sobre la cobertura de vacunación y el grado de cumplimiento de la pauta vacunal en la población infantil de la Comunidad de Madrid (CM).Se realizó un estudio observacional descriptivo. La población de estudio fueron niños residentes en la Comunidad de Madrid que alcanzaron la edad de vacunación en los períodos de financiación pública (2008 y 2010) y privada (2012 y 2013). La fuente de datos fue el sistema de información vacunal de la CM. Se estimó la cobertura de “vacunación completa” a los 24 meses y la cobertura de “vacunación a tiempo” de la primovacunación y de la pauta completa. La comparación según el tipo de financiación se efectuó mediante la razón de prevalencias (RP) y el porcentaje relativo del cambio. Se calculó el retraso entre dosis vacunales a los veinticuatro meses de edad.La cobertura de vacunación a tiempo fue del 72% cuando la financiación de la vacuna fue pública y del 64% cuando fue privada (RP=1,12). El retraso entre dosis fue mayor del 10% cuando la financiación fue privada.La financiación pública de la vacuna mejora el cumplimiento de la pauta vacunal.

To study the spatio-temporal distribution of cases of invasive pneumococcal disease (IPD) due to serotypes resistant to erythromycin and its relationship with community consumption of macrolides and childhood vaccination coverage.We selected IPD cases in adults over 59 years old, residents in the Community of Madrid (MC), notified in the period 2007-2016. The variables studied were obtained from the Vaccination Information Systems and the Pharmaceutical Service. The cut-off point (minimum inhibitory erythromycin concentration0.5 mg/L) of the EUCAST classification was used to define erythromycin resistant serotypes. We used JointPoint to estimate the incidence trends by erythromycin resistant serotypes included in the 13-valent vaccine (STPCV13) and not included in it (STnoPCV13). The association of these incidences with the community consumption of macrolides and vaccination coverage was made using Poisson models. Statistical scanning was used for the detection of temporal-spaces clusters of cases.1936 cases were identified, of which 427 erythromycin resistant serotypes were identified. The incidence of all cases due to resistant serotypes was decreasing (AAPC: -5,40%). During the period studied, the incidence of cases due to erythromycin resistant STPCV13 was decreasing with an annual percentage change (APC): -13.8 and was inversely associated with childhood vaccination coverage (IRR 0.641), while that of cases due to erythromycin resistant STnoPCV13 was ascending (APC): 4.5; and was not associated with coverage. 1 cluster was detected by STnoPCV13 and none by STPCV13 after the date of inclusion of the 13-valent in the childhood vaccination calendar.The decrease in IPD due to resistant STPCV13 was associated with an increase in childhood vaccination coverage. The presence of clusters due to STnoPCV13 after the date of inclusion of the 13-valent vaccine in the childhood vaccination calendar indicates serotypes replacement. The increase in cases of resistant STnoPCV13 could be related to the replacement of vaccine serotypes in nasopharyngeal colonization, facilitated by the consumption of macrolides still at high levels in MC.

The reverse transcriptase polymerase chain reaction (RT-PCR) continues to be the reference diagnostic method for the confirmation of COVID-19 cases; however, rapid antigen detection tests (RADT) have recently been developed. The purpose of the study is to assess the performance of rapid antigen-based COVID-19 testing in the context of hospital outbreaks. This was an observational, cross-sectional study. The study period was from October 2020 to January 2021. The “Panbio COVID-19 AG” RADT (Abbott) was performed and TaqPath COVID-19 test RT-PCR. The samples were obtained from hospitalised patients in suspected outbreak situations at the Ramón y Cajal Hospital. A hospital outbreak was defined as the presence of 3 or more epidemiologically linked cases. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of the RADT were calculated using RT-PCR as a reference. A total of 17 hospital outbreaks were detected in 11 hospital units during the study period, in which 34 RT-PCR and RADT screenings were performed. We obtained 541 samples, which were analysed with RT-PCR and a further 541 analysed with RADT. Six RADT tests gave conflicting results with the RT-PCR, 5 of them with a negative RADT and positive RT-PCR and one with positive RADT and a negative RT-PCR. The sensitivity of the RADT was 83.3% (65.3–94.4%) and the specificity was 99.8% (98.9–100%). The PPV was 96.2% (80.4–99.9%) and the NPV was 99% (97.7–99.7%). The RADT shows good diagnostic performance in patients on non-COVID-19 hospital wards, in the context of an outbreak.

Resumen Introduccion: la epidemia por el virus SARS-CoV-2 ha generado una situacion extraordinaria en la asistencia sanitaria de nuestro pais. La enorme sobrecarga de trabajo a la que han estado expuestos los profesionales sanitarios, la importante carga emocional, las situaciones estresantes y el miedo al contagio propio y de sus familiares, entre otros aspectos, han podido tener consecuencias en los profesionales, convirtiendolos en segundas victimas. El objetivo de este estudio es conocer la sobrecarga emocional de los trabajadores de areas de pacientes criticos por SARS-CoV-2 en un hospital terciario de la Comunidad de Madrid. Materiales y metodos: estudio descriptivo transversal, realizado mediante la cumplimentacion voluntaria por parte de los profesionales de areas de cuidados criticos de un cuestionario adaptado a partir de la Escala de Estres Agudo “EASE COVID-19”, consistente en 10 preguntas cerradas tipo Likert a las que se anadieron cuatro preguntas: sexo, categoria profesional, si trabajan habitualmente en areas de criticos y el sacrificio en sus rutinas. Los datos se recogieron en julio de 2020, para evaluar el impacto de la primera ola. Se realizo una descripcion de los datos y se analizo la asociacion entre las variables y la respuesta emocional. Resultados: un 54% de los encuestados mostro buen ajuste emocional. Lo que mas preocupo a los participantes fue la posibilidad de contagiar a sus familiares. Los colectivos con puntuaciones medias mas altas fueron los enfermeros, TCAE y celadores, mostrando ajuste emocional el 100% de los medicos, sin encontrarse diferencias por sexo. El 60% de los participantes modifico su rutina familiar, siendo los MIR los que presentaron mayor porcentaje. Conclusiones: la crisis sanitaria vivida ha convertido a los profesionales sanitarios en segundas victimas del SARS-CoV-2. Su deteccion es fundamental para ofrecerles los recursos y ayuda necesaria para garantizar su bienestar emocional, eliminando barreras y ayudandoles a salir reforzados.

Background: Overuse reduces the efficiency of healthcare systems and compromises patient safety. Different institutions have issued recommendations on the indication of preoperative chest X-rays, but the degree of compliance with these recommendations is unknown. This study investigates the frequency and characteristics of the inappropriateness of this practice. Methods: This is a descriptive observational study with analytical components, performed in a tertiary hospital in the Community of Madrid (Spain) between July 2018 and June 2019. The inappropriateness of preoperative chest X-ray tests was analyzed according to “Choosing Wisely”, “No Hacer” and “Essencial” initiatives and the cost associated with this practice was estimated in Relative Value and Monetary Units. Results: A total of 3449 preoperative chest X-ray tests were performed during the period of study. In total, 5.4% of them were unjustified according to the “No Hacer” recommendation and 73.3% according to “Choosing Wisely” and “Essencial” criteria, which would be equivalent to 5.6% and 11.8% of the interventions in which this test was unnecessary, respectively. One or more preoperative chest X-ray(s) were indicated in more than 20% of the interventions in which another chest X-ray had already been performed in the previous 3 months. A higher inappropriateness score was also recorded for interventions with an American Society of Anesthesiologists (ASA) grade ≥ III (16.5%). The Anesthesiology service obtained a lower inappropriateness score than other Petitioning Surgical Services (57.5% according to “Choosing Wisely” and “Essencial”, 4.1% according to “No Hacer”). Inappropriate indication of chest X-rays represents an annual cost of EUR 52,122.69 (170.1 Relative Value Units) according to “No Hacer” and EUR 3895.29 (2276.1 Relative Value Units) according to “Choosing Wisely” or “Essencial” criteria. Conclusions: There was wide variability between the recommendations that directly affected the degree of inappropriateness found, with the main reasons for inappropriateness being duplication of preoperative chest X-rays and the lack of consideration of the particularities of thoracic interventions. This inappropriateness implies a significant expense according to the applicable recommendations and therefore a high opportunity cost.

(1) Background: Identifying and measuring adverse events (AE) is a priority for patient safety, which allows us to define and prioritise areas for improvement and evaluate and develop solutions to improve health care quality. The aim of this work was to determine the prevalence of AEs in surgical and medical-surgical departments and to know the health impact of these AEs. (2) Methods: A cross-sectional study determining the prevalence of AEs in surgical and medical-surgical departments was conducted and a comparison was made among both clinical areas. A total of 5228 patients were admitted in 58 hospitals in Argentina, Colombia, Costa Rica, Mexico, and Peru, within the Latin American Study of Adverse Events (IBEAS), led by the Spanish Ministry of Health, the Pan American Health Organization, and the WHO Patient Safety programme. (3) Results: The global prevalence of AEs was 10.7%. However, the prevalence of AEs in surgical departments was 11.9%, while in medical-surgical departments it was 8.9%. The causes of these AEs were associated with surgical procedures (38.6%) and nosocomial infections (35.4%). About 60.6% of the AEs extended hospital stays by 30.7 days on average and 25.8% led to readmission with an average hospitalisation of 15 days. About 22.4% resulted in death, disability, or surgical reintervention. (4) Conclusions: Surgical departments were associated with a higher risk of experiencing AEs.

ObjectiveTo determine whether isolated patients admitted to hospital have a higher incidence of adverse events (AEs), to identify their nature, impact and preventability.DesignProspective cohort study with isolated and non-isolated patients.SettingOne public university hospital in the Valencian Community (southeast Spain).ParticipantsWe consecutively collected 400 patients, 200 isolated and 200 non-isolated, age ≥18 years old, to match according to date of entry, admission department, sex, age (±5 years) and disease severity from April 2017 to October 2018. Exclusion criteria: patients age Primary and secondary outcome measuresThe primary outcome as the AE, defined according to the National Study of Adverse Effects linked to Hospitalisation (Estudio Nacional Sobre los Efectos Adversos) criteria. Cumulative incidence rates and AE incidence density rates were calculated.ResultsThe incidence of isolated patients with AEs 16.5% (95% CI 11.4% to 21.6%) compared with 9.5% (95% CI 5.4% to 13.6%) in non-isolated (pConclusionsAEs were significantly higher in isolated patients compared with non-isolated patients, more than half being preventable and with HAIs as the primary cause. It is essential to improve training and the safety culture of healthcare professionals relating to the care provided to this type of patient.

Within the framework of the Patient Safety Strategy 2015-2020, the Regional Ministry of Health of the Community of Madrid developed two lines of action to consolidate the Patient Safety Culture through the dissemination of scientific knowledge in Patient Safety. The main objective was to identify, disseminate and improve access to relevant information on patient safety for patient-citizens, professionals and the organization itself through a pool of resources accessible on the Internet and intranet.After an analysis of the tools and communication channels available to disseminate knowledge in patient safety, the references of interest were selected by a group of experts, a consultation tool was developed in a navigable format on the internet and various dissemination actions were carried out to make it known.The Biblioteca Breve de Seguridad del Paciente (Brief Patient Safety Library) was developed, accessible for navigation on the web of the Community of Madrid and as a download document, with 154 references, structured in 4 areas: General resources (74 references), Resources by thematic area (51 references), Videos and multimedia (12 references) and Organizations and websites of interest (17 references).The Biblioteca Breve de Seguridad del Paciente (Brief Patient Safety Library) can help to promote the safety culture in health centers and to achieve greater citizen involvement in their safety, by providing reliable information on this crosscutting dimension of clinical practice.En el marco de la Estrategia de Seguridad del Paciente 2015-2020 la Consejería de Sanidad de la Comunidad de Madrid desarrolló dos líneas de actuación para consolidar la cultura de seguridad a través de la difusión del conocimiento científico en Seguridad del Paciente. El objetivo principal fue identificar, difundir y mejorar el acceso a la información relevante en seguridad del paciente a pacientes-ciudadanos, profesionales y a la propia organización mediante un catálogo de recursos accesible en internet e intranet.Tras un análisis de las herramientas y canales de comunicación disponibles para difundir el conocimiento en seguridad del paciente, se seleccionaron las referencias de interés por un grupo de expertos, se desarrolló una herramienta de consulta en un formato navegable en internet y se realizaron distintas acciones de difusión para darla a conocer.Se desarrolló la Biblioteca Breve de Seguridad del Paciente, accesible en la web de la Comunidad de Madrid para navegación y como documento para descargar, con 154 referencias, estructuradas en 4 áreas: Recursos generales (74 referencias), Recursos por Área temática (51 referencias), Videos y multimedia (12 referencias) y Organismos y sitios web de interés (17 referencias).La Biblioteca Breve de Seguridad del Paciente puede contribuir a impulsar la cultura de seguridad en los centros sanitarios y a lograr mayor implicación de los ciudadanos en su seguridad, al poner a su disposición información fiable sobre esta dimensión transversal de la práctica clínica.

The patient safety culture (PSC) in health institutions depends on various organizational and human factors. Our aim was to evaluate, as a teaching strategy, the knowledge in patient safety and perceptions about the PSC.A convenience sample, with 122 health professionals from Regional Minister of Health's patient safety courses attendees in 2015. Be- fore each course, were delivered a knowledge questionnaire about patient safety (own elaboration) and a validated PSC questionnaire (estimating 3 dimensions: managerial support, perception of safety and expectations / actions). Valuations on CSP were recategorized in positive, negative and neutral, identifying strengths (greater than or equal to 75% of positive evaluations) and opportunities for improvement (greater than or equal to 50% of negative evaluations). At the end of each course an anonymous satisfaction questionnaire was delivered.60% responded correctly to questions about knowledge in patient safety, identifying areas for improvement in safe practices (hand hygiene and microorganisms resistant to antibiotics, with 66% and 61% of incorrect answers, respectively), and in management of health risks (investigation and identification of adverse events, with 62% and 56% of incorrect answers, respectively). 80% considered the institutional PSC positive, and the perception of safety as an opportunity for improvement (63.9% of negative evaluations). Thus, 88% admitted worrying about patient safety only after adverse incidents, and 65% felt afraid to talk about them. The satisfaction with the teaching methodology was 9.3 points out of 10.The overall assessment of PSC was mostly positive, identifying specific areas for improvement that allowed orienting the training in patient safety, motivating the participants and suggesting intervention strategies to improve patient safety in our organizations.La cultura de seguridad del paciente (CSP) en las instituciones sanitarias depende de diversos factores organizativos y humanos. Nuestro objetivo fue evaluar, como estrategia docente, los conocimientos y percepciones sobre la CSP.Muestra de conveniencia, con 122 profesionales sanitarios y no sanitarios, que asistieron en 2015 a cursos sobre seguridad del paciente organizados por la Consejería de Sanidad de Madrid. Antes de cada curso, autocompletaron un cuestionario de conocimientos sobre seguridad del paciente (elaboración propia) y otro cuestionario validado sobre CSP (estimando 3 dimensiones: apoyo directivo, percepción de seguridad y expectativas/ acciones). Las valoraciones sobre la CSP se recategorizaron en positivas, negativas y neutras, identificando fortalezas (mayor o igual al 75% de valoraciones positivas) y oportunidades de mejora (mayor o igual al 50% de valoraciones negativas). Al finalizar cada curso, cumplimentaron un cuestionario anónimo de satisfacción.El 60% respondió correctamente a las preguntas sobre conocimientos en seguridad del paciente, identificando áreas de mejora en prácticas seguras (higiene de manos y microorganismos resistentes a antibióticos, con 66% y 61% de respuestas incorrectas, respectivamente), y en gestión de riesgos sanitarios (investigación e identificación de eventos adversos, con el 62% y 56% de respuestas incorrectas, respectivamente). El 80% consideró positiva la CSP institucional, y la percepción de seguridad como oportunidad de mejora (63,9% de valoraciones negativas). Así, el 88% reconocía preocuparse por la seguridad del paciente sólo tras incidentes adversos, y el 65% sentía miedo a hablar sobre estos. La satisfacción con la metodología docente fue de 9,3 puntos sobre 10.La valoración global de la CSP fue mayoritariamente positiva, identificándose áreas de mejora específicas utilizadas como estrategia docente para ilustrar conceptos, motivar a los participantes y sugerir estrategias de intervención para mejorar la cultura de seguridad del paciente en nuestras organizaciones.

ResumenObjetivoAnalizar la adherencia al tratamiento de la infección tuberculosa (TIT) e identificar los factores de riesgo para su cumplimiento.DiseñoEstudio observacional de cohortes históricas.EmplazamientoHospital Universitari Sant Joan d’Alacant (Alicante).ParticipantesTodos los sujetos con una prueba de tuberculina (PT) realizada durante el estudio de contactos (EC) de tuberculosis durante 6 años.ResultadosSe incluyeron en el análisis 764 contactos. El 59,7% de los 566 pacientes que terminaron el EC presentaron infección tuberculosa (IT). De los pacientes con IT, el 45,6% no iniciaron tratamiento y los factores asociados fueron: edad (36-65 años; RR: 5,8; IC 95%: 1,2-27,5 y > 65 años; RR: 11,3; IC 95%: 2,0-64,0), relación social con el caso índice de tuberculosis (RR: 2,2; IC 95%: 1,2-3,8) e induración de la PT (≥ 15mm; RR: 0,5; IC 95%: 0,3-0,9). La tasa de cumplimiento fue del 80,4% entre los que comenzaron el TIT. La pauta de tratamiento 7-9H se asoció con mayor cumplimiento del TIT (RR: 12,7; IC 95%: 1,5-107,3).ConclusionesLa tasa de cumplimiento del TIT fue elevada entre los que iniciaron tratamiento. Casi la mitad de los contactos con IT no iniciaron tratamiento y los factores asociados fueron: edad, relación social e induración de la PT. La pauta de tratamiento se asoció con mayor cumplimiento. Debemos conocer con precisión los factores asociados a la adherencia al tratamiento de la IT en cada área de salud y actuar sobre los grupos de riesgo, y de esta manera aproximar el control global de la tuberculosis.AbstractObjectiveTo analyze adherence to treatment of tuberculosis infection and to identify risk factors for its compliance.DesignAn observational historical cohort study.SettingHospital Universitari Sant Joan d’Alacant (Alicante).ParticipantsAll patients with a tuberculin skin test (TST) done during tuberculosis contact tracing during 6 years.ResultsWe included 764 tuberculosis contacts in the analysis. 59.7% of the 566 patients who completed the contact tracing, had tuberculosis infection (TI). Of the patients with TI, 45.6% had not started treatment for tuberculosis infection (TTBI). Factors associated with not starting TTBI were: age (36-65 years, RR: 5.8; 95% CI: 1.2-27.5, and > 65 years, RR: 11.3; 95% CI: 2.0-64.0), the social relationship with TB case (RR: 2.2; 95% CI 1.2-3.8), and the TST reaction (≥ 15mm; RR: 0.5; 95% CI: 0.3-0.9). The completion rate for TTBI was 80.4% among people who started therapy. The treatment regimen was associated with greater compliance to TTBT (7-9H, RR: 12.7; 95% CI: 1.5-107.3).ConclusionsThe treatment compliance rate of Tuberculosis infection was high among people who started therapy. Almost a half of the contacts with TI did not start treatment, and associated factors were: age, social relationship, and the TST reaction. The treatment regimen was associated with greater compliance. It is important to know the factors associated with adherence to treatment of TI in each health area, and focus efforts on risk groups; thereby approaching the global control of tuberculosis.

BackgroundAdverse events (AEs) epidemiology is the first step to improve practice in the healthcare system. Usually, the preferred method used to estimate the magnitude of the problem is the retrospective cohort study design, with retrospective reviews of the medical records. However this data collection involves a sophisticated sampling plan, and a process of intensive review of sometimes very heavy and complex medical records. Cross-sectional survey is also a valid and feasible methodology to study AEs.ObjectivesThe aim of this study is to compare AEs detection using two different methodologies: cross-sectional versus retrospective cohort design.SettingSecondary and tertiary hospitals in five countries: Argentina, Colombia, Costa Rica, Mexico and Peru.ParticipantsThe IBEAS Study is a cross-sectional survey with a sample size of 11 379 patients. The retrospective cohort study was obtained from a 10% random sample proportional to hospital size from the entire IBEAS Study population.MethodsThis study compares the 1-day prevalence of the AEs obtained in the IBEAS Study with the incidence obtained through the retrospective cohort study.ResultsThe prevalence of patients with AEs was 10.47% (95% CI 9.90 to 11.03) (1191/11 379), while the cumulative incidence of the retrospective cohort study was 19.76% (95% CI 17.35% to 22.17%) (215/1088). In both studies the highest risk of suffering AEs was seen in Intensive Care Unit (ICU) patients. Comorbid patients and patients with medical devices showed higher risk.ConclusionThe retrospective cohort design, although requires more resources, allows to detect more AEs than the cross-sectional design.

To find comparative elements for quality control in major ambulatory surgery (MAS) units.Descriptive and comparative study of the Ambulatory Care Index (AI) and Substitution Index (SI) in the Santa Cristina Hospital Surgery Service (Madrid, Spain) compared to Key Indicators (KI) of the National Health Service (NHS).7,817 MAS procedures (between 2006 and 2014) were analysed. The average annual AI was 54%, higher (p0.0001) than «ambulatory surgery» KI. The hernia outpatient procedures (average 72%) were also superior to the national KI (p0.0001), but ambulatory haemorrhoidectomy (average 33.6%) was clearly lower (p0.0001).KI of the NHS are useful and allow to establish a proper development in the global AI and hernia outpatient surgery with opportunities for improvement in haemorrhoidectomy. Their collection should be careful, not including minor surgeries. Also, their usefulness could be increased if data was broken down by speciality and by complexity.

ObjectivesIdentify the sources of overuse from the point of view of the Spanish primary care professionals, and analyse the frequency of overuse due to pressure from patients in addition to the responses when professionals face these demands.DesignA cross-sectional study.SettingPrimary care in Spain.ParticipantsA non-randomised sample of 2201 providers (general practitioners, paediatricians and nurses) was recruited during the survey.Primary and secondary outcome measuresThe frequency, causes and responsibility for overuse, the frequency that patients demand unnecessary tests or procedures, the profile of the most demanding patients, and arguments for dissuading the patient.ResultsIn all, 936 general practitioners, 682 paediatricians and 286 nurses replied (response rate 18.6%). Patient requests (67%) and defensive medicine (40%) were the most cited causes of overuse. Five hundred and twenty-two (27%) received requests from their patients almost every day for unnecessary tests or procedures, and 132 (7%) recognised granting the requests. The lack of time in consultation, and information about new medical advances and treatments that patients could find on printed and digital media, contributed to the professional’s inability to adequately counter this pressure by patients. Clinical safety (49.9%) and evidence (39.4%) were the arguments that dissuaded patients from their requests the most. Cost savings was not a convincing argument (6.8%), above all for paediatricians (4.3%). General practitioners resisted more pressure from their patients (x2=88.8, P2=175.7, PConclusionSatisfying the patient and patient uncertainty about what should be done and defensive medicine practices explains some of the frequent causes of overuse. Safety arguments are useful to dissuade patients from their requests.

Resumen Antecedentes La ocurrencia de efectos adversos (EA) es un problema presente en todos los niveles asistenciales y genera una carga importante de morbimortalidad. En Espana se han realizado 2 estudios nacionales de EA: uno en hospitales y otro en atencion primaria; sin embargo, aun no se han estudiado aquellos EA que detectados durante un proceso de hospitalizacion hubieran tenido su origen en una atencion sanitaria previa. El objetivo de este estudio es conocer las caracteristicas de los pacientes con EA y la frecuencia, naturaleza, evitabilidad, gravedad e impacto de los EA prehospitalarios que se detectaron en la hospitalizacion indice, y comparar los de origen ambulatorio y los de origen no ambulatorio. Metodo Estudio de serie de casos, con componentes analiticos, de una muestra de sujetos incluidos en el Estudio Nacional de Efectos Adversos ligados a la Hospitalizacion (ENEAS). Los datos cualitativos se presentan como proporciones con su intervalo de confianza (IC). Para el analisis comparativo de datos cualitativos, se utilizo el test de χ2. Resultados De un total de 5.624 pacientes, un 2,3% (n=131) (IC del 95%: 1,94–2,72) presento algun EA prehospitalario, y de estos, en el 40,5% (n=53) (IC del 95%: 32,05–48,86) el EA fue evitable. En 44 pacientes el origen del EA fue ambulatorio y en 85 pacientes el origen fue no ambulatorio. Los pacientes con EA ambulatorio son mujeres de edad avanzada y hombres de mediana edad que consultan por problemas medicos y el EA suele estar relacionado con la utilizacion de medicamentos. Los pacientes con EA no ambulatorio con mayor frecuencia son hombres de edad avanzada, que ingresan en servicios tanto medicos como quirurgicos y los EA estan relacionados, ademas de con los medicamentos, con las infecciones nosocomiales y los procedimientos. Conclusiones Las caracteristicas de los pacientes con EA y los EA ocurridos durante el periodo de “prehospitalizacion” son diferentes si se originan en un contexto ambulatorio o no ambulatorio. Por lo tanto, las estrategias de prevencion deben tener en cuenta estas diferencias.

Resumen Objetivo La practica clinica es una actividad acompanada de riesgos e incertidumbre. Los objetivos son estimar la incidencia de pacientes quirurgicos con efectos adversos (EA), analizar los factores asociados y estimar su impacto e identificar las posibilidades de prevencion. Pacientes y metodo Estudio ambispectivo de los pacientes atendidos en una unidad de un servicio de cirugia general de un hospital de tercer nivel. La revision de todos los ingresos se realizo de forma prospectiva con una guia de cribado, examinandose de manera retrospectiva con un cuestionario modular todas las historias clinicas que cumplieron criterios de cribado. Resultados Se revisaron 989 historias con un valor predictivo positivo (VPP) para EA de la guia de cribado de 53%. La incidencia acumulada de pacientes con EA fue del 17,8% y la densidad de incidencia de EA de 1,92/100 dias de hospitalizacion. Los factores intrinsecos y extrinsecos se asociaron a mayor riesgo de EA; los eventos mas frecuentes fueron las infecciones nosocomiales (54,4%) y los problemas quirurgicos (31,8%) y los de medicacion (7,4%). El 66,8% de los EA fueron considerados moderados (el 53,5% de todos los EA evitables). Conclusiones El cuestionario de cribado ha sido util para la valoracion de EA. Los EA son frecuentes en pacientes quirurgicos y repercuten en la utilizacion de los recursos hospitalarios. Los factores asociados mas relevantes fueron la estancia, la intervencion quirurgica y los factores extrinsecos. De los EA, destaco la infeccion de herida quirurgica. Por su impacto, dos tercios fueron moderados y se considero evitables la mitad de todos los EA.

Objective Clinical practice is an activity accompanied by risks and uncertainties. The objectives are: to determine the incidence of patients with adverse events (AE) in a general surgery unit; to analyse the associated factors; to consider their impact and to identify the prevention possibilities. Patients and method Ambispective study in patients taken care of in a general surgery unit in a tertiary hospital. Every admission was prospectively reviewed using a screening guide, with all the clinical histories that fulfilled screening criteria being examined retrospectively using a modular questionnaire. Results A total of 989 histories were reviewed, the positive predictive value (PPV) of the screening guide for AE was 53%. The accumulated incidence of patients with AE was 17.8% and the incidence density of AE was 1.92 for every 100 days of hospitalisation. Intrinsic and extrinsic risk factors were associated to greater risk of EA, the most frequent events being: nosocomial infections (54.4%), surgical problems (31.8%), and problems associated with medication (7.4%). A total of 66.8% of the AE were considered moderate, with 53.5% of all AE being preventable. Conclusions The screening questionnaire was useful for the valuation of adverse events. AE are common in surgical patients which has an effect on the use of other hospital resources. The most important associated factors were: length of stay, surgical and extrinsic factors and surgical wound infection as the main AE. Two thirds of AE were considered moderate and half of all AE were considered avoidable.

Resumen Objetivo Evaluar la efectividad de las intervenciones orientadas a reducir la hospitalizacion inadecuada identificada con metodos con criterios explicitos e independientes del diagnostico. Material y metodos Revision sistematica de la literatura para identificar estudios de evaluacion de intervenciones de reduccion del uso inadecuado, seguida de una sintesis narrativa. Se incluyeron trabajos en ingles, frances o espanol, con disenos experimentales, cuasiexperimentales u observacionales, con o sin grupo control. Resultados Se hallaron 15 estudios que evaluaban las intervenciones de reduccion de la hospitalizacion inadecuada (2 ensayos clinicos, 8 cuasiexperimentales con grupo control y 5 con disenos antes-despues sin grupo control), en su mayoria realizados en Estados Unidos (3 en Espana). La variedad de tipos de hospital, servicios implicados, tipos de paciente, unidades de muestreo, instrumentos y presentaciones de resultados impidio la sintesis cuantitativa. Las intervenciones mas usadas fueron la retroinformacion y las administrativas. Todos los estudios excepto 2 mostraron reducciones en el porcentaje de estancias inadecuadas, admisiones inadecuadas, estancias inadecuadas en el dia previo al del alta y la duracion de la estancia. Las intervenciones intensivas, que combinaban componentes educativos, de retroinformacion, autoevaluacion por los propios clinicos y componentes administrativos, mostraron los mejores resultados. Conclusiones La literatura revisada indica que diversas intervenciones son efectivas para reducir la hospitalizacion inadecuada, sobre todo las concurrentes, directas y activas, que alcanzan a los facultativos que prestan la asistencia y combinan varios componentes.

Resumen Objetivos La aplicacion de un protocolo diagnostico, consensuado de manera interdisciplinaria y adaptado localmente, puede disminuir la frecuencia de uso de la radiografia en el manejo del traumatismo craneal infantil y mejorar la calidad asistencial y el consumo de recursos. Pacientes y metodo Auditoria clinica con dos fases, de 12 meses cada una, antes y despues de la aplicacion de un protocolo diagnostico basado en las recomendaciones disponibles en la bibliografia y adaptado al medio asistencial. Resultados Tras la aplicacion del protocolo, la frecuencia de uso de la radiografia paso del 45,8 al 38,9% y la proporcion de inadecuacion de la prueba se redujo del 25,1 al 14,7%. No hubo diferencias estadisticamente significativas en la utilizacion de la tomografia computarizada y se observo una reduccion del numero de ingresos. Conclusiones La aplicacion del protocolo no solo redujo el numero total de radiografias solicitadas, sino que su utilizacion se adecuo mejor a la situacion clinica del paciente. Se deben realizar de forma sistematica auditorias clinicas de la actividad desarrollada en las unidades de urgencias y favorecer la puesta en marcha de cambios que permitan una mejora continua de la calidad asistencial.

To address the current economic crisis, governments have promoted austerity measures that have affected the taxpayer-funded health system. We report the findings of a study exploring the perceptions of primary care physicians in Madrid (Spain) on measures implemented in the Spanish health system.We carried out a qualitative study in two primary health care centres located in two neighbourhoods with unemployment and migrant population rates above the average of those in Madrid. Interviews were conducted with 12 primary health care physicians. Interview data were analysed by using thematic analysis and by adopting some elements of the grounded theory approach.Two categories were identified: evaluation of austerity measures and evaluation of decision-making in this process. Respondents believed there was a need to promote measures to improve the taxpayer-funded health system, but expressed their disagreement with the measures implemented. They considered that the measures were not evidence-based and responded to the need to decrease public health care expenditure in the short term. Respondents believed that they had not been properly informed about the measures and that there was adequate professional participation in the prioritization, selection and implementation of measures. They considered physician participation to be essential in the decision-making process because physicians have a more patient-centred view and have first-hand knowledge of areas requiring improvement in the system.It is essential that public authorities actively involve health care professionals in decision-making processes to ensure the implementation of evidence-based measures with strong professional support, thus maintaining the quality of care.

Summary Objectives: To identify readmissions related to problems of quality of hospital care. Material and methods: Descriptive study of hospitalization episodes (uniform hospital discharge data set) in a district hospital. Read- mission was defined as an episode of hospitalization of a patient occurring within a certain time period after an initial admission (in- dex admission). The clinical relationship (agreement between Inter- national Classification of Diseases-ninth version-Clinical Modifica- tion (ICD-9-CM) and diagnosis-related group) and the time interval between hospitalization episodes were analyzed. Results: A total of 20.9% of readmissions were found to be related to quality of care and approximately 50% were produced within 1 month of discharge after the index admission. Significant differen- ces were found with patients readmitted for other reasons: these pa- tients were 7.8 years younger and the number of diagnoses and complications was lower. Length of hospital stay was a risk factor. Conclusions: Problems of quality of care lead to a considerable number of readmissions and are the main cause of obstetric read- missions; most diagnoses are included under the heading of "iatro- genic" in the ICD-9-CM. Analysis of these readmissions may be useful to design strategies for improving quality of care.

Se analiza si son aplicables los principios y metodos de mejora de la calidad asistencial en hidrologia medica e hidroterapia. Se describen los metodos para realizar un analisis de la calidad de la asistencia y se senalan la necesidad de practicar la Medicina Basada en la Evidencia en Hidrologia Medica, asi como la necesidad de definir criterios, estandares y elaborar indicadores.

Objective. To analyze the relationship between the appearance of adverse events (AEs) and both patient comorbidities and the use of medical devices. Design. Retrospective medical records review study. Setting. Twenty-four Spanish public hospitals. Participants. Clinical records of 5624 discharged patients. Main Outcome Measure. Incidence of AEs. Results. Patients aged .65 have 2.4 times the risk of experiencing an AE compared with those aged ,65. The presence of certain comorbidities and devices (neoplasia, chronic hepatic alteration, cardiac insufficiency, coronary disease, high blood pressure, urethral catheterization, catheterization of a vessel, tracheostomy or stay of .7 days) were associated with developing an AE during hospitalization. There is a trend effect if we consider the number of comorbidities and the number of devices used. Thus, the risk of an AE in subjects who present no comorbidities was 3.2%, which rose to 9.9% in those with one intrinsic risk factor, 16.7% in those with two and 29.3% in those with three or more. Similarly, subjects without extrinsic risk factor experienced an AE in 4.4% of cases, which rose to 9.6% when there was one risk factor, to 13.4% when there were two and to 33.0% when there were three or more risk factors. The effect of some of these pathologies and that associated with age disappeared on adjusting in line with other variables. Conclusions. The true risk resides in the number of exposures to potentially iatrogenic actions, rather than being intrinsic to age or the presence of certain comorbidities.

The occurrence of adverse events is a problem at all levels of care and creates a significant burden of morbidity and mortality. In Spain there have been significant investigations of adverse effects (AE) in hospitals and primary care, however, studies of pre-hospital care are not yet developed. The aim of this study was to determine the frequency, type, preventability, severity and impact of "pre-hospital" adverse events, which were detected in the hospitalization index and the comparing those that occurred in ambulatory and non-ambulatory care.Case Series Study, with analytical components, of a sample of subjects included in the "National study of adverse events related to hospitalization (ENEAS). Qualitative data are presented as proportions with confidence intervals. For comparative analysis of qualitative data, we used the chi-square test.Of a total of 5624 patients, 2.3% (N=131) ((95%)CI: 1.94-2.72) had an AE that occurred prior to hospitalization or "pre-hospital", and 40.5% of these (N=53) ((95%)CI: 32.05-48.86) were preventable. In 44 patients the AE had its origin in ambulatory care and 85 patients in non-ambulatory care. The characteristic of patients with ambulatory AE are men and older women (median 76 years) who consulted for medical problems (84.1%) and the AE were related to medication in 77.8%. The characteristic of patients with non-ambulatory AE, were men (median 73 years), consulting for medical and surgical problems (44,7-55,3%) and the EA is related to medications, infections and procedures.The characteristics of patients with AE and undesirable effects that occurred during pre-hospitalization period depended on whether they originated during ambulatory care or non-ambulatory care. Therefore prevention strategies should take these differences into account.

Aprender de los errores impulsando el desarrollo de sistemas de notificacion y registro de sucesos adversos (efectos adversos o incidentes) fue uno de los programas iniciales de la Alianza Mundial para la Seguridad del Paciente. La seguridad del paciente es un objetivo prioritario en la mejora de la calidad de los sistemas sanitarios, lo que ha llevado a la busqueda de herramientas que permitan mejorar el conocimiento del origen de sucesos adversos1. Tradicionalmente los errores medicos han sido analizados de forma retrospectiva a traves de los comites de morbimortalidad y, en ocasiones, mediante el analisis de las reclamaciones. La frecuencia y la distribucion del riesgo asistencial pueden estimarse por estudios retrospectivos (revision de historias clinicas), transversales y prospectivos. Los estudios retrospectivos son mas faciles de realizar y mas efectivos en la estimacion de la incidencia de sucesos adversos (SA), pero solo detectan los efectos adversos (EA) documentados, subestiman otros prevenibles y pueden pasar inadvertidos errores graves si no han producido dano. Ademas, en general no permiten analizar los factores implicados o causas profundas. Los estudios prospectivos son mas costosos en tiempo y recursos, cuantifican mejor la incidencia de los EA evitables, describen mejor las causas y consecuencias y son utiles en los programas de reduccion de riesgos. Por otra parte, podemos realizar el analisis del dano de manera individualizada por medio de tecnicas de investigacion de accidentes, como el analisis de causas raiz, para determinar la cascada causal y los fallos latentes, o bien de manera agrupada, por medio de estudios epidemiologicos que permiten caracterizar el dano e identificar las circunstancias que le confieren caracter evitable. Los sistemas de notificacion y registro de incidentes y eventos adversos estan destinados a conocer los problemas mas frecuentes y aprender de los errores y evitar que puedan volver a repetirse. Su importancia radica en que estudian tanto EA –con dano– como incidentes. No pretenden hacer una estimacion de la frecuencia de los EA, sino que son una forma de obtener una valiosa informacion sobre la cascada de acontecimientos que llevan a la produccion de un EA. El error humano puede ser enfocado de dos maneras: como un problema de las personas o de los sistemas2. El enfoque personal atribuye los errores a ciertos procesos de los individuos, tales como olvido, distraccion, deficiente motivacion, falta de cuidado, sobrecarga de trabajo, cansancio, estres, negligencia o imprudencia. La vision moderna de la causa del error medico considera la atencion a la salud como un sistema altamente complejo, donde interactuan muchos elementos y factores, y donde la responsabilidad no esta en uno solo de ellos. Asi la mayoria de los EA suelen generarse en una cadena causal que involucra recursos, procesos, pacientes y prestadores de servicios, y el resultado de fallos esta en el sistema en el que los profesionales trabajan mas que en una mala practica individual. Los sistemas de notificacion de SA pueden ser de dos tipos: obligatorios, orientados a la busqueda de la responsabilidad, se centran en episodios que producen lesiones graves o muertes, y voluntarios, que proporcionan informacion util para la mejora de la seguridad, centrandose en los incidentes (donde no ha habido dano) o en errores que han producido dano minimo. Su objetivo es identificar areas o elementos vulnerables del sistema antes de que se produzca el dano en los pacientes y formar a los profesionales sobre lo aprendido con el analisis de casos previos. Las principales ventajas que reportan los sistemas de notificacion y registro de SA son su contribucion a la estandarizacion de la taxonomia, la identificacion de los puntos debiles del sistema que permiten analizar sus causas, y el aumento de la conciencia sobre los problemas de seguridad, que facilita el compromiso de los profesionales. Ademas, la notificacion de incidentes en particular permite entender por que el accidente no llego a ocurrir. Muchos formularios para el registro de incidentes identifican las barreras que previenen las situaciones adversas que pueden desencadenar un episodio grave. Estos datos permiten al analista identificar las barreras que han demostrado su efectividad en los incidentes estudiados. Por la influencia del sector de la aviacion se ha asumido que centrarse en los datos de monitorizacion de incidentes –en ausencia de dano– anade mas valor a la mejora de la calidad que centrarse unicamente en el analisis de los efectos adversos, ya que se puede abordar los problemas de seguridad antes de que produzcan dano. De tal modo que si el sistema fuera lo suficientemente exhaustivo como para registrar todo lo que su

ResumenIntroducciónSe pretende describir el perfil de usuario y determinar su motivación para visitar el servicio de urgencias hospitalario (SUH) por iniciativa propia.MétodoSe elaboró un cuestionario ad hoc que se aplicó por selección consecutiva a los pacientes que podían esperar asistencia (nivel 1 del triage) durante una semana de noviembre de 2002.ResultadosRespondieron el cuestionario 348 pacientes, acudiendo por iniciativa propia el 82,5%. De éstos, el 17,7% desconocía el funcionamiento de atención primaria respecto a urgencias; el 18,8% consultó con su centro de salud; el 55,0% refirió preferencia por el SUH y el 13,5% acudió por demora en otros niveles asistenciales. El 50,5% era menor de 40 años y el 9,2%, extranjero.ConclusionesLos cambios en el patrón de consumo de servicios sanitarios pueden comprometer la organización del Sistema Nacional de Salud, si no se adapta la oferta a la necesidad expresada y/o se interviene modulando el uso racional de los recursos sanitarios.AbstractIntroductionThe aim of this study was to determine the reasons why patients use hospital emergency services (HES) on their own initiative and the characteristics of these users.MethodAn ad hoc questionnaire was designed and applied by consecutive selection to patients who could have waited for medical care (level 1 triage) over a 1-week period in November 2002.ResultsA total of 348 patients completed the questionnaire; 82.5% attended on their own initiative; of these, 17.7% reported they did not know how Primary Care worked in relation to the Emergency Services; 18.8% consulted a Primary Care physician; 55.0% preferred the HES and 13.5% attended because of a delay in another health care setting. Half the patients (50.5%) were younger than 40 years old and 9.2% were foreigners.ConclusionsChanges in health services’ consumption patterns could jeopardize the public health system unless supply is adapted to the demand expressed and/or interventions are performed to educate the public in rational health services’ consumption.