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for which there is little information on the adequate dosage&#44; is also common &#40;for instance&#44; in off-label use or the treatment of rare diseases such as cystic fibrosis&#41;&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">For potent drugs&#44; when only a small fraction of the adult dose is required for children&#44; it becomes very easy to cause errors because of miscalculation or misplacement of the decimal point&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#8211;13</span></a> Furthermore&#44; it is often necessary to manipulate adult formulations to obtain smaller doses for paediatric patients&#46; These practises are associated with a high risk for errors&#44; as the bioavailability of a drug that has been manipulated is often unknown and unpredictable&#46; There is a lack of information on compatibility and stability&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">&#8220;High alert medications&#8221; are defined as drugs that bear a heightened risk of causing significant patient harm or even death when they are used in error&#46; This definition does not suggest that errors associated with these drugs are necessarily more common&#44; but that the consequences of these errors are more severe for the patients&#46; Thus&#44; high alert medications should be a priority objective in any hospital&#39;s clinical safety programmes&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Systematic mechanisms to promote safe medication are probably important factors that allow the translation of a safety culture into outcomes&#44; but they may be ineffective in the context of a poor safety culture&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">An overall organisational culture based on trust and error disclosure predicts the intent to disclose a hypothetical error in a patient&#44; while teamwork and a safety culture do not&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Isolated ME rates&#44; based on incident notifications&#44; do not provide a valid measure of patient safety&#46; A high error rate may be suggestive of dangerous practises or of an organisational culture that promotes error reporting&#46; A low rate of MEs could suggest that an organisation engages in successful and safe practises&#44; or that it has a particularly punitive approach to reporting&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">Reported near misses lead to corrective action at the organisational level when managers perceive a substantial potential for harm and preventability&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Observational studies<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;18</span></a> help detect safety problems&#44; but are very labour-intensive&#46; The idea for this study came from an observational study that we had conducted in the paediatric oncology unit&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">To measure the safety interventions related to the use of medications we have analysed the variation in reporting rates of MEs&#44; variation in incidence rates of MEs with harm per 10&#44;000 distributed doses&#44; and improvement in the responses to safety questionnaires&#46;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">20&#44;21</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">The incidence density of MEs is calculated as the number of errors per 100 patients per duration of hospital stay in days&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">We selected 2 factors for our intervention&#44; one based on the culture of error disclosure&#44; and one based on trust&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> The decentralisation of reporting and monitoring of MEs at the management level may lead to increased motivation to report in healthcare professionals&#46; It would make sense to make it easier to measure harm&#44; understand causes&#44; seek solutions&#44; implement strategies for improvement&#44; and measure the impact of these strategies within a group of closely interacting professionals&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">The 2010&#8211;2014 Plan de Calidad del Sistema Sanitario P&#250;blico de Andaluc&#237;a &#40;Quality Plan of the Public Health System of Andalusia&#41;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> contemplates the decentralisation of patient safety organisation to the management units&#46; This inspired us to institute a safety committee in the paediatrics management unit&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">The reviewed literature expresses that further research is needed to understand how the way reporting is done affects learning from errors and error prevention&#44; and to identify factors that may lead to improved reporting&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">Our hypothesis&#44; based on the available evidence&#44; is that a feeling of trust towards a safety committee within the management unit and easier reporting by means of a simple computer application could contribute to the motivation to report MEs and lead to improved reporting rates&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Our objective was to analyse the impact on error notification of the implementation of a decentralised multidisciplinary safety committee in the paediatrics management unit and the concurrent introduction of a networked computer application for ME reporting by monitoring the error reports and evaluating the safety-improvement strategies implemented by the management unit&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Methodology</span><p id="par0115" class="elsevierStylePara elsevierViewall">We conducted an observational&#44; descriptive&#44; pre-post intervention study&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Description of new strategy</span><p id="par0120" class="elsevierStylePara elsevierViewall">1&#46; A networked computer application was designed for the confidential reporting and analysis of MEs in the management unit&#46;</p><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Fields of an error report in the computer application</span><p id="par0125" class="elsevierStylePara elsevierViewall">Error description&#44; severity classification&#44; affected organs or systems&#44; patient age&#44; clinical manifestations&#44; sex&#44; drug&#47;active ingredient&#44; dose&#44; error date&#44; day of the week&#44; type of incident&#44; setting where the error originated&#44; medication process &#40;dispensation&#44; prescription&#44; transcription&#44; preparation&#44; administration&#41;&#44; setting where the error was detected&#44; cause of the error&#44; person who made the error&#44; contributing factors&#44; person who discovered the error&#44; measures proposed or taken to prevent the same error from occurring&#46;</p><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Types of incident</span><p id="par0130" class="elsevierStylePara elsevierViewall">Wrong medication&#44; pharmacological treatment or dose omission&#44; wrong dose&#44; incorrect frequency of administration&#44; wrong dosage form&#44; preparation error&#44; manipulation and&#47;or packaging errors&#44; wrong administration technique&#44; wrong route of administration&#44; wrong rate of administration&#44; wrong time of administration&#44; wrong patient&#44; wrong duration of treatment&#44; insufficient treatment monitoring&#44; deteriorated drug&#44; patient noncompliance&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Severity categories</span><p id="par0135" class="elsevierStylePara elsevierViewall"><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></p><p id="par0140" class="elsevierStylePara elsevierViewall">The application was introduced to the staff in clinical meetings of the medical staff and in small group meetings &#40;6 people&#41; for the nursing staff&#46; In both cases&#44; the contents had been developed by consensus</p><p id="par0145" class="elsevierStylePara elsevierViewall">2&#46; A safety committee was instituted within a paediatrics management unit with the participation of clinicians&#44; nurses&#44; and pharmacists&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Monthly meetings lasting one hour were held the first Thursday of every month to analyse MEs and develop improvement strategies based on the analysis&#46; Error analysis feedback was provided to the healthcare staff and the consensus improvement strategies were notified by the submission of meeting minutes to managerial staff&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Analysis of the impact of new strategy</span><p id="par0155" class="elsevierStylePara elsevierViewall">3&#46; An audit was done to analyse MEs&#8212;those notified in paper to the central safety committee in the 12 months prior to implementation&#44; as well as those reported by means of the decentralised computer application to the safety committee of the management unit in the 9 months after implementation&#8212;and the strategies generated by the analysis of MEs in the pre- and postintervention periods&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Measured variables&#58; number of reported errors per 10&#44;000 days of hospitalisation&#44; overall for each period and by month&#59; number of errors with harm per 10&#44;000 days of hospitalisation&#59; type&#59; severity category&#59; step of the process&#59; professional category of reporter&#59; and medication involved&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">The OpenEpi<span class="elsevierStyleSup">&#174;</span><a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">23</span></a> application was used to do the statistical analysis&#46; We performed a descriptive analysis of the variables&#44; calculating the various relative frequencies&#46;</p></span></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Results</span><p id="par0170" class="elsevierStylePara elsevierViewall">Preintervention period &#40;January&#8211;December 2011&#41;&#58; 13 error reports&#47;17&#44;124 days of hospitalisation &#40;7&#46;5&#47;10&#44;000&#41; in children aged 4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4 years&#59; mean monthly number of reports<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>standard deviation &#40;SD&#41;&#58; 1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">Number of errors with harm or which needed monitoring reported per 10&#44;000 days of hospitalisation&#58; 2&#46;9&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">Postintervention period &#40;January&#8211;September 2012&#41;&#58; 42 error reports&#47;11&#44;801 days of hospitalisation &#40;36&#47;10&#44;000&#41;&#44; in children aged 5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4 years&#59; mean monthly number of reports<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>SD&#58; 5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">Number of errors with harm or which required monitoring reported per 10&#44;000 days of hospitalisation&#58; 3&#46;4&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">There was a 4&#46;6-fold increase in the number of ME reports&#47;10&#44;000 days of hospitalisation in the postintervention period relative to the preintervention period&#46; When we compared the rate of error reporting in the 2 periods&#44; we obtained a rate ratio of 0&#46;21 &#40;95&#37; CI&#44; 0&#46;11&#8211;0&#46;39&#41; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">The total number of errors with harm that required reporting per 10&#44;000 days of hospitalisation hardly changed between periods &#40;rate ratio&#44; 0&#46;77&#59; 95&#37; CI&#44; 0&#46;31&#8211;1&#46;91&#59; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>&#46;05&#41;&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">The severity categories for the MEs per 10&#44;000 days of hospitalisation reported in the pre- and postintervention periods are shown in <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0205" class="elsevierStylePara elsevierViewall">The reported number of potential errors and errors without harm per 10&#44;000 days of hospitalisation increased by a factor of 17&#46;4 in the postintervention period relative to the preintervention period &#40;rate ratios&#44; 0&#46;005&#59; 95&#37; CI&#44; 0&#46;001&#8211;0&#46;026&#59; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41;&#46;</p><p id="par0210" class="elsevierStylePara elsevierViewall">In the preintervention period&#44; all the reported errors with harm occurred during administration&#46; In the postintervention period&#44; 75&#37; corresponded to prescription errors and 25&#37; to administration errors&#46;</p><p id="par0215" class="elsevierStylePara elsevierViewall">In the preintervention period&#44; the errors with harm&#44; all of them related to the process of administration&#44; were&#58; morphine hydrochloride overdose&#44; vancomycin extravasation and intrathecal methotrexate overdose&#46; The errors that required monitoring were administration of a NSAID to an allergic patient and of an excess dose of phenobarbital&#46;</p><p id="par0220" class="elsevierStylePara elsevierViewall">The errors with harm in the postintervention period were pain during infusion of paracetamol &#40;administration&#41;&#44; prescription of an overdosage of dactinomycin&#44; anaphylactic shock secondary to metamizol administration&#44; and prescription error consisting of swapping the doses of 2 antibiotics&#46;</p><p id="par0225" class="elsevierStylePara elsevierViewall">The number of MEs per 10&#44;000 days of hospitalisation according to the step in the medication process is shown in <a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#46; The steps carried out by the nursing staff &#40;transcription&#44; preparation&#44; and administration&#41; and by clinicians &#40;prescription&#41; are grouped together in <a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#46; In the preintervention period&#44; paper reports did not need to specify the steps of the process following the format used later in the postintervention period&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0230" class="elsevierStylePara elsevierViewall">In the preintervention period&#44; 100&#37; of the errors were reported by the nursing staff&#59; in the postintervention period&#44; 79&#37; were reported by nurses&#44; 7&#37; by physicians&#44; and 14&#37; by pharmacists&#46;</p><p id="par0235" class="elsevierStylePara elsevierViewall">The rate of reported errors per 10&#44;000 days of hospitalisation in the steps carried out by the nursing staff increased by a factor of 3&#46;7 &#40;rate ratio&#44; 0&#46;026&#59; 95&#37; CI&#44; 0&#46;01&#8211;0&#46;57&#59; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41;&#44; and in the steps carried out by physicians&#44; it increased by a factor of 5&#46;4 &#40;rate ratio&#44; 0&#46;018&#59; 95&#37; CI&#44; 0&#46;004&#8211;0&#46;074&#59; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41;&#46;</p><p id="par0240" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0010">Table 1</a> shows the therapeutic classification of the drugs involved in the reports&#46; We performed this classification based on the list proposed by our working group after the paediatrics management unit reached a consensus following a review of the literature&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14&#44;24</span></a></p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0245" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a> shows the reported causes of MEs&#44; and <a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a> the number of errors per month notified in the pre- and postintervention periods&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><elsevierMultimedia ident="fig0025"></elsevierMultimedia></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Discussion</span><p id="par0250" class="elsevierStylePara elsevierViewall">The interventions to promote a culture of safety included multicomponent strategies&#44; with the formation of teams and mechanisms to support communication&#46; Assessing the implemented strategies based on the outcomes was considered of paramount importance&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">25</span></a></p><p id="par0255" class="elsevierStylePara elsevierViewall">In calculating reporting rates&#44; we have used 10&#44;000 days of hospitalisation as the denominator&#44; rather than the 100 commonly used in observational study&#46; We did this because the direct observation method is about 1000 times more efficacious than the method of voluntary reporting&#44; although it tends to miss errors with harm&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;21</span></a></p><p id="par0260" class="elsevierStylePara elsevierViewall">The substantial increase in reporting unaccompanied by an increase in reports of error with harm implies that the motivation to report of healthcare professionals has increased&#44; as manifested by the 17-fold increase in the reporting of potential errors and errors without harm&#46;</p><p id="par0265" class="elsevierStylePara elsevierViewall">The involvement of nursing staff in reporting has increased&#44; as has that of physicians and pharmacists&#46; We were not able to assess the safety climate by means of a survey&#44; as recommended by the Ministerio de Sanidad y Consumo &#40;the Ministry of Health and Consumers&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">26</span></a> nor the training in safety&#46; The method of training in small groups applied to the nursing staff was more effective than training during clinical sessions&#44; as nurses have reported errors 11 times more often than specialist physicians&#44; who are the smallest professional collective&#46;</p><p id="par0270" class="elsevierStylePara elsevierViewall">Consistent with what we found in our study&#44; communications in recent national congresses also mention the lack of electronic prescription support as an important cause of MEs &#40;44&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">27</span></a></p><p id="par0275" class="elsevierStylePara elsevierViewall">The following measures&#44; among others&#44; are recommended to evaluate the efficacy of patient safety strategies&#58; account of the theoretical model explaining why the safety intervention would work&#44; detailed description of the intervention so it can be repeated&#44; description of how the intervention changes over time&#44; and assessment of the effect of the intervention on outcomes&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">28</span></a> We followed these steps in our study&#46; A drop in reporting was observed starting on the seventh month&#44; which coincided with the summer&#46; Thus&#44; we propose refresher training on safety and ME reporting every 6 months&#46;</p><p id="par0280" class="elsevierStylePara elsevierViewall">We believe that the system used in the study&#44; based on user-friendly software&#44; confidential and nonpunitive reporting&#44; training on error reporting based on presentations developed by consensus&#44; and a safety committee within the unit that provides feedback&#44; is successful in fighting the barriers to reporting described in the literature&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;6&#44;11</span></a> In the past&#44; the management unit had not been working in depth towards achieving an error culture and an error disclosure culture&#46;</p><p id="par0285" class="elsevierStylePara elsevierViewall">During the postintervention period&#44; several strategies were proposed in the meetings of the safety committee of the management unit&#44; which were partially implemented&#58; &#40;1&#41; double-checking of paediatric chemotherapy prescriptions&#59; &#40;2&#41; double-checking of high alert drug preparation&#59; &#40;3&#41; introduction of an electronic form for drug prescription and administration&#59; &#40;4&#41; multidisciplinary development of a manual for the administration of high alert drugs in paediatrics &#40;in press&#41; and &#40;5&#41; divulgation of the directives for the prescription and administration of drugs&#46;</p><p id="par0290" class="elsevierStylePara elsevierViewall">The development of interventions&#44; feedback&#44; and the implemented strategies involved the collaboration of clinical&#44; nursing&#44; and pharmacy staff at all times&#46;</p><p id="par0295" class="elsevierStylePara elsevierViewall">The programme described here has been implemented at no cost&#44; as the training sessions have been integrated in previously established programmes&#44; and the safety committee operates during regular working hours&#46; Also&#44; when it is implemented in a new unit&#44; the central safety committee of the hospital is granted access to the computer application&#44; so that experiences in improvement can be shared&#46;</p><p id="par0300" class="elsevierStylePara elsevierViewall">In the future&#44; the safety committee of the unit will develop training sessions to refresh and update theoretical knowledge and techniques for the improvement of information divulgation&#46; The manual for the use of high alert drugs in paediatric care&#44; already developed&#44; will be circulated&#44; and we will evaluate the safety climate and knowledge of the different professional collectives before and after these interventions&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Conclusions</span><p id="par0305" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">-</span><p id="par0310" class="elsevierStylePara elsevierViewall">All professional collectives became involved during the postintervention period&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">-</span><p id="par0315" class="elsevierStylePara elsevierViewall">The motivation of healthcare professionals to report has increased&#44; as evinced by the considerable increase in the reporting of potential errors&#46; The reporting of errors with harm or errors requiring monitoring hardly increased in the same period&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">-</span><p id="par0320" class="elsevierStylePara elsevierViewall">The monthly analysis of the causes of errors in the committee is quick and effective&#44; and is manifested in solutions that are implemented on the go and studied for feedback in short intervals of time&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">-</span><p id="par0325" class="elsevierStylePara elsevierViewall">All of the above suggests that this decentralised reporting system is ideal to plan and monitor safety interventions in the management unit&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">-</span><p id="par0330" class="elsevierStylePara elsevierViewall">We need to evolve at the structural and procedural levels &#40;electronic prescription validated by the pharmacy&#41;&#59; offering the necessary safety training&#59; reassessing work loads&#59; and considering the protocols needed in the unit&#46;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">-</span><p id="par0335" class="elsevierStylePara elsevierViewall">We need to maintain the staff&#39;s awareness of this subject by means of periodic refresher education&#44; as the interest in reporting declines with the passing of time&#46;</p></li></ul></p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Conflicts of interest</span><p id="par0340" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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            1 => "Sistema de notificaci&#243;n de errores"
            2 => "Comit&#233; de seguridad"
            3 => "Medicamentos de alto riesgo"
            4 => "Pediatr&#237;a"
            5 => "Acontecimientos adversos prevenibles"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">To analyse the impact of a multidisciplinary and decentralised safety committee in the paediatric management unit&#44; and the joint implementation of a computing network application for reporting medication errors&#44; monitoring the follow-up of the errors&#44; and an analysis of the improvements introduced&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0015">Materials and methods</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">An observational&#44; descriptive&#44; cross-sectional&#44; pre-post intervention study was performed&#46; An analysis was made of medication errors reported to the central safety committee in the twelve months prior to introduction&#44; and those reported to the decentralised safety committee in the management unit in the nine months after implementation&#44; using the computer application&#44; and the strategies generated by the analysis of reported errors&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0020">Measured variables</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Number of reported errors&#47;10&#44;000 days of stay&#44; number of reported errors with harm per 10&#44;000 days of stay&#44; types of error&#44; categories based on severity&#44; stage of the process&#44; and groups involved in the notification of medication errors&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0025">Results</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Reported medication errors increased 4&#46;6-fold&#44; from 7&#46;6 notifications of medication errors per 10&#44;000 days of stay in the pre-intervention period to 36 in the post-intervention&#44; rate ratio 0&#46;21 &#40;95&#37; CI&#59; 0&#46;11&#8211;0&#46;39&#41; &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41;&#46; The medication errors with harm or requiring monitoring reported per 10&#44;000 days of stay&#44; was virtually unchanged from one period to the other ratio rate 0&#46;77 &#40;95&#37; IC&#59; 0&#46;31&#8211;1&#46;91&#41; &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>&#46;05&#41;&#46; The notification of potential errors or errors without harm per 10&#44;000 days of stay increased 17&#46;4-fold &#40;rate ratio 0&#46;005&#44; 95&#37; CI&#59; 0&#46;001&#8211;0&#46;026&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41;&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0030">Conclusions</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">The increase in medication errors notified in the post-intervention period is a reflection of an increase in the motivation of health professionals to report errors through this new method&#46;</p>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0040">Objetivo</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Analizar el impacto en la notificaci&#243;n de errores de medicaci&#243;n de la puesta en marcha de un comit&#233; de seguridad multidisciplinar descentralizado en la unidad de gesti&#243;n pedi&#225;trica&#44; e implantaci&#243;n conjunta de una aplicaci&#243;n inform&#225;tica en red para la comunicaci&#243;n de errores de medicaci&#243;n&#44; mediante seguimiento de los errores y an&#225;lisis de las mejoras&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0045">Material y m&#233;todos</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Estudio observacional&#44; descriptivo&#44; transversal pre-post intervenci&#243;n&#46; Se analizan los errores de medicaci&#243;n notificados a la comisi&#243;n central de seguridad&#44; en los 12 meses previos a la implantaci&#243;n&#44; y los notificados mediante la aplicaci&#243;n inform&#225;tica descentralizada a la comisi&#243;n de seguridad de la unidad de gesti&#243;n&#44; en los 9 meses posteriores&#44; y las estrategias generadas por el an&#225;lisis&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0050">Variables medidas</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">N&#250;mero de errores notificados por 10&#46;000 d&#237;as de estancia&#44; n&#250;mero de errores con da&#241;o por 10&#46;000 d&#237;as de estancia&#44; tipo&#44; categor&#237;a en funci&#243;n de la gravedad&#44; fase del proceso&#44; colectivo que notifica y medicamentos implicados&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0055">Resultados</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Se multiplican por 4&#44;6 los errores de medicaci&#243;n notificados &#8212;7&#44;6 notificaciones por 10&#46;000 d&#237;as de estancia en el periodo preintervenci&#243;n y 36 en el postintervenci&#243;n&#8212;&#44; raz&#243;n de tasas de 0&#44;21 &#40;IC 95&#37;&#58; 0&#44;11&#8211;0&#44;39&#41; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#46;</p><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">No cambian pr&#225;cticamente los errores con da&#241;o o que necesitaron monitorizaci&#243;n notificados por 10&#46;000 d&#237;as de estancia de un periodo a otro&#44; raz&#243;n de tasas&#58; 0&#44;77 &#40;IC95&#37;&#58; 0&#44;31&#8211;1&#44;91&#41; p<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#46; Se multiplica por 17&#44;4 la notificaci&#243;n de errores sin da&#241;o o potenciales por 10&#46;000 d&#237;as de estancia&#44; raz&#243;n de tasas&#58; 0&#44;005 &#40;IC 95&#37;&#58; 0&#44;001&#8211;0&#44;026&#41; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0060">Conclusiones</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">El incremento de los errores de medicaci&#243;n notificados en el periodo postintervenci&#243;n es reflejo del aumento en la motivaci&#243;n de los profesionales sanitarios para notificar a trav&#233;s de este nuevo m&#233;todo&#46;</p>"
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Guerrero-Aznar MD&#44; Jim&#233;nez-Mesa E&#44; Cotrina-Luque J&#44; Villalba-Moreno A&#44; Cumplido-Corbacho R&#44; Fern&#225;ndez-Fern&#225;ndez L&#46; Validaci&#243;n en pediatr&#237;a de un m&#233;todo para notificaci&#243;n y seguimiento de errores de medicaci&#243;n&#46; An Pediatr &#40;Barc&#41;&#46; 2014&#59;81&#58;360&#8211;367&#46;</p>"
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    ]
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        "figura" => array:1 [
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        "descripcion" => array:1 [
          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Medication error categories by severity&#46; Cat A&#58; incident or circumstance that may cause harm&#59; cat B&#58; an error occurred but did not reach the patient&#59; cat C&#58; the error reached the patient&#44; but did not cause patient harm&#59; cat D&#58; the error reached the patient and did not cause patient harm&#44; but required monitoring&#47;intervention&#59; cat E&#58; error with harm&#46;</p>"
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        "figura" => array:1 [
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          "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Reported medication error by step of the medication process&#46;</p>"
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        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
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          "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Reported medication errors grouped by steps of medication process&#46;</p>"
        ]
      ]
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        "etiqueta" => "Figure 4"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
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          "en" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Reported causes for medication errors&#46;</p>"
        ]
      ]
      4 => array:7 [
        "identificador" => "fig0025"
        "etiqueta" => "Figure 5"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
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        "descripcion" => array:1 [
          "en" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Number of reported errors by month in the preintervention &#40;January&#8211;December 2011&#41; and postintervention &#40;January&#8211;September 2012&#41; periods&#46;</p>"
        ]
      ]
      5 => array:7 [
        "identificador" => "tbl0010"
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">G-CSF&#58; granulocyte colony stimulating factors&#59; PPIs&#58; proton pump inhibitors&#46;</p><p id="spar0100" class="elsevierStyleSimplePara elsevierViewall">Percentages of ISMP high alert drugs are presented in boldface&#46;</p><p id="spar0105" class="elsevierStyleSimplePara elsevierViewall">Source&#58; ISMP<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a>&#59; Cotrina Luque et al&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">24</span></a></p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Type of medication&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Preintervention &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>13&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Postintervention &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>42&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">Antibiotic</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">31&#37;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">29&#37;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Antifungals &#40;liposomal&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Antivirals&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Gammaglobulins&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">IV and SC insulin</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">8&#37;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">IV opioids</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">8&#37;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">Inhaled and IV general anaesthetics</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">8&#37;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">5&#37;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">Cytostatics</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">8&#37;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">31&#37;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">G-CSF&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Analgesics <span class="elsevierStyleBold">&#40;IV paracetamol&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">8&#37;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">10&#37;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">Cardiac glycosides &#40;IV inotropes&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleBold">2&#37;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">Antiepileptics</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleBold">2&#37;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Antiparkinsonians&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Diuretics&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Hormones&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">2&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Other cardiovascular drugs&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">PPIs&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">15&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">Cat a&#58;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Cat b&#58;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Cat c&#58;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Cat d&#58;&nbsp;\t\t\t\t\t\t\n
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Errores de medicaci&#243;n"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:4 [
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                            1 => "R&#46; Mart&#237;n Mu&#241;&#243;z"
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                            3 => "C&#46; Codina Jan&#233;"
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            1 => array:3 [
              "identificador" => "bib0010"
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                          "etal" => false
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                0 => array:1 [
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                            0 => "Estudio EMOPEM"
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              "referencia" => array:1 [
                0 => array:1 [
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                  "contribucion" => array:1 [
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                          "autores" => array:6 [
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                  ]
                  "host" => array:1 [
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                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "R&#46; Kaushal"
                            1 => "D&#46;W&#46; Bates"
                            2 => "C&#46; Landrigan"
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                        ]
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                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
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                  "contribucion" => array:1 [
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                        0 => array:2 [
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                            1 => "M&#46;A&#46; Ghaleb"
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                      ]
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                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
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                      ]
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                  ]
                  "host" => array:1 [
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                  "contribucion" => array:1 [
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                        0 => array:2 [
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                            2 => "P&#46; Impicciatore"
                            3 => "A&#46; Mohn"
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                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
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            12 => array:3 [
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              "etiqueta" => "13"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "Y&#46;W&#46; Yeung"
                            1 => "C&#46;L&#46; Tuleu"
                            2 => "I&#46;C&#46;K&#46; Wong"
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                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Paed Perin Drug Ther"
                        "fecha" => "2004"
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Original Article
Validation of a method for notifying and monitoring medication errors in paediatrics
Validación en pediatría de un método para notificación y seguimiento de errores de medicación
M.D. Guerrero-Aznara,
Corresponding author
, E. Jiménez-Mesab, J. Cotrina-Luquea, A. Villalba-Morenoa, R. Cumplido-Corbachob, L. Fernández-Fernándezb
a Unidad de gestión de Farmacia, Hospital Virgen del Rocío, Sevilla, Spain
b Unidad de gestión de Pediatría, Hospital Virgen del Rocío, Sevilla, Spain
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takes a nonpunitive approach to reporting&#59; encourages reporting of both potential and actual errors of patient injuries resulting from errors&#59; and provides feedback of error analysis and recommendations&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Additional characteristics of a reporting system include&#58; ease of use&#59; availability of both electronic and paper formats&#59; standard taxonomy&#59; severity of outcomes&#59; retrievable data&#59; report generation&#59; and root-cause analysis&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The number of errors that occur in the daily delivery of healthcare is much higher than we would think&#46; It is estimated that 50&#8211;96&#37; of errors go unreported&#46; In the EMOPEM study&#44;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> the mean error rate for the 22 participating hospitals was 21&#46;72&#37;&#44; with a minimum of 2&#46;85&#37; and a maximum of 79&#46;02&#37;&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Underreporting of MEs can compromise patient safety&#46; The perceived barriers to notification are fear of consequences&#59; a blame culture&#59; lack of training in reporting&#44; time to report&#44; organisational leadership and support&#44; legal protection&#44; guidelines and policies&#44; staff and resources&#59; lack of understanding why reporting is needed&#59; concern that no action will follow reporting&#59; non-anonymous reporting&#59; and reporting perceived to be bureaucratic&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;6</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Paediatric rates of potentially serious MEs can be 3 times greater than adult rates&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;8</span></a> The risk of MEs in paediatrics is particularly high because of the need for dosage calculations based on the patient&#39;s weight&#44; age&#44; or body surface area and the patient&#39;s condition&#46; Unlicensed use of medications&#44; for which there is little information on the adequate dosage&#44; is also common &#40;for instance&#44; in off-label use or the treatment of rare diseases such as cystic fibrosis&#41;&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">For potent drugs&#44; when only a small fraction of the adult dose is required for children&#44; it becomes very easy to cause errors because of miscalculation or misplacement of the decimal point&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#8211;13</span></a> Furthermore&#44; it is often necessary to manipulate adult formulations to obtain smaller doses for paediatric patients&#46; These practises are associated with a high risk for errors&#44; as the bioavailability of a drug that has been manipulated is often unknown and unpredictable&#46; There is a lack of information on compatibility and stability&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">&#8220;High alert medications&#8221; are defined as drugs that bear a heightened risk of causing significant patient harm or even death when they are used in error&#46; This definition does not suggest that errors associated with these drugs are necessarily more common&#44; but that the consequences of these errors are more severe for the patients&#46; Thus&#44; high alert medications should be a priority objective in any hospital&#39;s clinical safety programmes&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Systematic mechanisms to promote safe medication are probably important factors that allow the translation of a safety culture into outcomes&#44; but they may be ineffective in the context of a poor safety culture&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">An overall organisational culture based on trust and error disclosure predicts the intent to disclose a hypothetical error in a patient&#44; 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but are very labour-intensive&#46; The idea for this study came from an observational study that we had conducted in the paediatric oncology unit&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">To measure the safety interventions related to the use of medications we have analysed the variation in reporting rates of MEs&#44; variation in incidence rates of MEs with harm per 10&#44;000 distributed doses&#44; and improvement in the responses to safety questionnaires&#46;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">20&#44;21</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">The incidence density of MEs is calculated as the number of errors per 100 patients per duration of hospital stay in days&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">We selected 2 factors for our intervention&#44; 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and to identify factors that may lead to improved reporting&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">Our hypothesis&#44; based on the available evidence&#44; is that a feeling of trust towards a safety committee within the management unit and easier reporting by means of a simple computer application could contribute to the motivation to report MEs and lead to improved reporting rates&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Our objective was to analyse the impact on error notification of the implementation of a decentralised multidisciplinary safety committee in the paediatrics management unit and the concurrent introduction of a networked computer application for ME reporting by monitoring the error reports and evaluating the safety-improvement strategies implemented by the management unit&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Methodology</span><p id="par0115" class="elsevierStylePara elsevierViewall">We conducted an observational&#44; descriptive&#44; pre-post intervention study&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Description of new strategy</span><p id="par0120" class="elsevierStylePara elsevierViewall">1&#46; A networked computer application was designed for the confidential reporting and analysis of MEs in the management unit&#46;</p><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Fields of an error report in the computer application</span><p id="par0125" class="elsevierStylePara elsevierViewall">Error description&#44; severity classification&#44; affected organs or systems&#44; patient age&#44; clinical manifestations&#44; sex&#44; drug&#47;active ingredient&#44; dose&#44; error date&#44; day of the week&#44; type of incident&#44; setting where the error originated&#44; medication process &#40;dispensation&#44; prescription&#44; transcription&#44; preparation&#44; administration&#41;&#44; setting where the error was detected&#44; cause of the error&#44; person who made the error&#44; contributing factors&#44; person who discovered the error&#44; measures proposed or taken to prevent the same error from occurring&#46;</p><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Types of incident</span><p id="par0130" class="elsevierStylePara elsevierViewall">Wrong medication&#44; pharmacological treatment or dose omission&#44; wrong dose&#44; incorrect frequency of administration&#44; wrong dosage form&#44; preparation error&#44; manipulation and&#47;or packaging errors&#44; wrong administration technique&#44; wrong route of administration&#44; wrong rate of administration&#44; wrong time of administration&#44; wrong patient&#44; wrong duration of treatment&#44; insufficient treatment monitoring&#44; deteriorated drug&#44; patient noncompliance&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Severity categories</span><p id="par0135" class="elsevierStylePara elsevierViewall"><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></p><p id="par0140" class="elsevierStylePara elsevierViewall">The application was introduced to the staff in clinical meetings of the medical staff and in small group meetings &#40;6 people&#41; for the nursing staff&#46; In both cases&#44; the contents had been developed by consensus</p><p id="par0145" class="elsevierStylePara elsevierViewall">2&#46; A safety committee was instituted within a paediatrics management unit with the participation of clinicians&#44; nurses&#44; and pharmacists&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Monthly meetings lasting one hour were held the first Thursday of every month to analyse MEs and develop improvement strategies based on the analysis&#46; Error analysis feedback was provided to the healthcare staff and the consensus improvement strategies were notified by the submission of meeting minutes to managerial staff&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Analysis of the impact of new strategy</span><p id="par0155" class="elsevierStylePara elsevierViewall">3&#46; An audit was done to analyse MEs&#8212;those notified in paper to the central safety committee in the 12 months prior to implementation&#44; as well as those reported by means of the decentralised computer application to the safety committee of the management unit in the 9 months after implementation&#8212;and the strategies generated by the analysis of MEs in the pre- and postintervention periods&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Measured variables&#58; number of reported errors per 10&#44;000 days of hospitalisation&#44; overall for each period and by month&#59; number of errors with harm per 10&#44;000 days of hospitalisation&#59; type&#59; severity category&#59; step of the process&#59; professional category of reporter&#59; and medication involved&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">The OpenEpi<span class="elsevierStyleSup">&#174;</span><a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">23</span></a> application was used to do the statistical analysis&#46; We performed a descriptive analysis of the variables&#44; calculating the various relative frequencies&#46;</p></span></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Results</span><p id="par0170" class="elsevierStylePara elsevierViewall">Preintervention period &#40;January&#8211;December 2011&#41;&#58; 13 error reports&#47;17&#44;124 days of hospitalisation &#40;7&#46;5&#47;10&#44;000&#41; in children aged 4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4 years&#59; mean monthly number of reports<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>standard deviation &#40;SD&#41;&#58; 1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">Number of errors with harm or which needed monitoring reported per 10&#44;000 days of hospitalisation&#58; 2&#46;9&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">Postintervention period &#40;January&#8211;September 2012&#41;&#58; 42 error reports&#47;11&#44;801 days of hospitalisation &#40;36&#47;10&#44;000&#41;&#44; in children aged 5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4 years&#59; mean monthly number of reports<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>SD&#58; 5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">Number of errors with harm or which required monitoring reported per 10&#44;000 days of hospitalisation&#58; 3&#46;4&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">There was a 4&#46;6-fold increase in the number of ME reports&#47;10&#44;000 days of hospitalisation in the postintervention period relative to the preintervention period&#46; When we compared the rate of error reporting in the 2 periods&#44; we obtained a rate ratio of 0&#46;21 &#40;95&#37; CI&#44; 0&#46;11&#8211;0&#46;39&#41; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">The total number of errors with harm that required reporting per 10&#44;000 days of hospitalisation hardly changed between periods &#40;rate ratio&#44; 0&#46;77&#59; 95&#37; CI&#44; 0&#46;31&#8211;1&#46;91&#59; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>&#46;05&#41;&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">The severity categories for the MEs per 10&#44;000 days of hospitalisation reported in the pre- and postintervention periods are shown in <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0205" class="elsevierStylePara elsevierViewall">The reported number of potential errors and errors without harm per 10&#44;000 days of hospitalisation increased by a factor of 17&#46;4 in the postintervention period relative to the preintervention period &#40;rate ratios&#44; 0&#46;005&#59; 95&#37; CI&#44; 0&#46;001&#8211;0&#46;026&#59; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41;&#46;</p><p id="par0210" class="elsevierStylePara elsevierViewall">In the preintervention period&#44; all the reported errors with harm occurred during administration&#46; In the postintervention period&#44; 75&#37; corresponded to prescription errors and 25&#37; to administration errors&#46;</p><p id="par0215" class="elsevierStylePara elsevierViewall">In the preintervention period&#44; the errors with harm&#44; all of them related to the process of administration&#44; were&#58; morphine hydrochloride overdose&#44; vancomycin extravasation and intrathecal methotrexate overdose&#46; The errors that required monitoring were administration of a NSAID to an allergic patient and of an excess dose of phenobarbital&#46;</p><p id="par0220" class="elsevierStylePara elsevierViewall">The errors with harm in the postintervention period were pain during infusion of paracetamol &#40;administration&#41;&#44; prescription of an overdosage of dactinomycin&#44; anaphylactic shock secondary to metamizol administration&#44; and prescription error consisting of swapping the doses of 2 antibiotics&#46;</p><p id="par0225" class="elsevierStylePara elsevierViewall">The number of MEs per 10&#44;000 days of hospitalisation according to the step in the medication process is shown in <a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#46; The steps carried out by the nursing staff &#40;transcription&#44; preparation&#44; and administration&#41; and by clinicians &#40;prescription&#41; are grouped together in <a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#46; In the preintervention period&#44; paper reports did not need to specify the steps of the process following the format used later in the postintervention period&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0230" class="elsevierStylePara elsevierViewall">In the preintervention period&#44; 100&#37; of the errors were reported by the nursing staff&#59; in the postintervention period&#44; 79&#37; were reported by nurses&#44; 7&#37; by physicians&#44; and 14&#37; by pharmacists&#46;</p><p id="par0235" class="elsevierStylePara elsevierViewall">The rate of reported errors per 10&#44;000 days of hospitalisation in the steps carried out by the nursing staff increased by a factor of 3&#46;7 &#40;rate ratio&#44; 0&#46;026&#59; 95&#37; CI&#44; 0&#46;01&#8211;0&#46;57&#59; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41;&#44; and in the steps carried out by physicians&#44; it increased by a factor of 5&#46;4 &#40;rate ratio&#44; 0&#46;018&#59; 95&#37; CI&#44; 0&#46;004&#8211;0&#46;074&#59; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41;&#46;</p><p id="par0240" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0010">Table 1</a> shows the therapeutic classification of the drugs involved in the reports&#46; We performed this classification based on the list proposed by our working group after the paediatrics management unit reached a consensus following a review of the literature&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14&#44;24</span></a></p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0245" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a> shows the reported causes of MEs&#44; and <a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a> the number of errors per month notified in the pre- and postintervention periods&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><elsevierMultimedia ident="fig0025"></elsevierMultimedia></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Discussion</span><p id="par0250" class="elsevierStylePara elsevierViewall">The interventions to promote a culture of safety included multicomponent strategies&#44; with the formation of teams and mechanisms to support communication&#46; Assessing the implemented strategies based on the outcomes was considered of paramount importance&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">25</span></a></p><p id="par0255" class="elsevierStylePara elsevierViewall">In calculating reporting rates&#44; we have used 10&#44;000 days of hospitalisation as the denominator&#44; rather than the 100 commonly used in observational study&#46; We did this because the direct observation method is about 1000 times more efficacious than the method of voluntary reporting&#44; although it tends to miss errors with harm&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;21</span></a></p><p id="par0260" class="elsevierStylePara elsevierViewall">The substantial increase in reporting unaccompanied by an increase in reports of error with harm implies that the motivation to report of healthcare professionals has increased&#44; as manifested by the 17-fold increase in the reporting of potential errors and errors without harm&#46;</p><p id="par0265" class="elsevierStylePara elsevierViewall">The involvement of nursing staff in reporting has increased&#44; as has that of physicians and pharmacists&#46; We were not able to assess the safety climate by means of a survey&#44; as recommended by the Ministerio de Sanidad y Consumo &#40;the Ministry of Health and Consumers&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">26</span></a> nor the training in safety&#46; The method of training in small groups applied to the nursing staff was more effective than training during clinical sessions&#44; as nurses have reported errors 11 times more often than specialist physicians&#44; who are the smallest professional collective&#46;</p><p id="par0270" class="elsevierStylePara elsevierViewall">Consistent with what we found in our study&#44; communications in recent national congresses also mention the lack of electronic prescription support as an important cause of MEs &#40;44&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">27</span></a></p><p id="par0275" class="elsevierStylePara elsevierViewall">The following measures&#44; among others&#44; are recommended to evaluate the efficacy of patient safety strategies&#58; account of the theoretical model explaining why the safety intervention would work&#44; detailed description of the intervention so it can be repeated&#44; description of how the intervention changes over time&#44; and assessment of the effect of the intervention on outcomes&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">28</span></a> We followed these steps in our study&#46; A drop in reporting was observed starting on the seventh month&#44; which coincided with the summer&#46; Thus&#44; we propose refresher training on safety and ME reporting every 6 months&#46;</p><p id="par0280" class="elsevierStylePara elsevierViewall">We believe that the system used in the study&#44; based on user-friendly software&#44; confidential and nonpunitive reporting&#44; training on error reporting based on presentations developed by consensus&#44; and a safety committee within the unit that provides feedback&#44; is successful in fighting the barriers to reporting described in the literature&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;6&#44;11</span></a> In the past&#44; the management unit had not been working in depth towards achieving an error culture and an error disclosure culture&#46;</p><p id="par0285" class="elsevierStylePara elsevierViewall">During the postintervention period&#44; several strategies were proposed in the meetings of the safety committee of the management unit&#44; which were partially implemented&#58; &#40;1&#41; double-checking of paediatric chemotherapy prescriptions&#59; &#40;2&#41; double-checking of high alert drug preparation&#59; &#40;3&#41; introduction of an electronic form for drug prescription and administration&#59; &#40;4&#41; multidisciplinary development of a manual for the administration of high alert drugs in paediatrics &#40;in press&#41; and &#40;5&#41; divulgation of the directives for the prescription and administration of drugs&#46;</p><p id="par0290" class="elsevierStylePara elsevierViewall">The development of interventions&#44; feedback&#44; and the implemented strategies involved the collaboration of clinical&#44; nursing&#44; and pharmacy staff at all times&#46;</p><p id="par0295" class="elsevierStylePara elsevierViewall">The programme described here has been implemented at no cost&#44; as the training sessions have been integrated in previously established programmes&#44; and the safety committee operates during regular working hours&#46; Also&#44; when it is implemented in a new unit&#44; the central safety committee of the hospital is granted access to the computer application&#44; so that experiences in improvement can be shared&#46;</p><p id="par0300" class="elsevierStylePara elsevierViewall">In the future&#44; the safety committee of the unit will develop training sessions to refresh and update theoretical knowledge and techniques for the improvement of information divulgation&#46; The manual for the use of high alert drugs in paediatric care&#44; already developed&#44; will be circulated&#44; and we will evaluate the safety climate and knowledge of the different professional collectives before and after these interventions&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Conclusions</span><p id="par0305" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">-</span><p id="par0310" class="elsevierStylePara elsevierViewall">All professional collectives became involved during the postintervention period&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">-</span><p id="par0315" class="elsevierStylePara elsevierViewall">The motivation of healthcare professionals to report has increased&#44; as evinced by the considerable increase in the reporting of potential errors&#46; The reporting of errors with harm or errors requiring monitoring hardly increased in the same period&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">-</span><p id="par0320" class="elsevierStylePara elsevierViewall">The monthly analysis of the causes of errors in the committee is quick and effective&#44; and is manifested in solutions that are implemented on the go and studied for feedback in short intervals of time&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">-</span><p id="par0325" class="elsevierStylePara elsevierViewall">All of the above suggests that this decentralised reporting system is ideal to plan and monitor safety interventions in the management unit&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">-</span><p id="par0330" class="elsevierStylePara elsevierViewall">We need to evolve at the structural and procedural levels &#40;electronic prescription validated by the pharmacy&#41;&#59; offering the necessary safety training&#59; reassessing work loads&#59; and considering the protocols needed in the unit&#46;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">-</span><p id="par0335" class="elsevierStylePara elsevierViewall">We need to maintain the staff&#39;s awareness of this subject by means of periodic refresher education&#44; as the interest in reporting declines with the passing of time&#46;</p></li></ul></p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Conflicts of interest</span><p id="par0340" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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        "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">To analyse the impact of a multidisciplinary and decentralised safety committee in the paediatric management unit&#44; and the joint implementation of a computing network application for reporting medication errors&#44; monitoring the follow-up of the errors&#44; and an analysis of the improvements introduced&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0015">Materials and methods</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">An observational&#44; descriptive&#44; cross-sectional&#44; pre-post intervention study was performed&#46; An analysis was made of medication errors reported to the central safety committee in the twelve months prior to introduction&#44; and those reported to the decentralised safety committee in the management unit in the nine months after implementation&#44; using the computer application&#44; and the strategies generated by the analysis of reported errors&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0020">Measured variables</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Number of reported errors&#47;10&#44;000 days of stay&#44; number of reported errors with harm per 10&#44;000 days of stay&#44; types of error&#44; categories based on severity&#44; stage of the process&#44; and groups involved in the notification of medication errors&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0025">Results</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Reported medication errors increased 4&#46;6-fold&#44; from 7&#46;6 notifications of medication errors per 10&#44;000 days of stay in the pre-intervention period to 36 in the post-intervention&#44; rate ratio 0&#46;21 &#40;95&#37; CI&#59; 0&#46;11&#8211;0&#46;39&#41; &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41;&#46; The medication errors with harm or requiring monitoring reported per 10&#44;000 days of stay&#44; was virtually unchanged from one period to the other ratio rate 0&#46;77 &#40;95&#37; IC&#59; 0&#46;31&#8211;1&#46;91&#41; &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>&#46;05&#41;&#46; The notification of potential errors or errors without harm per 10&#44;000 days of stay increased 17&#46;4-fold &#40;rate ratio 0&#46;005&#44; 95&#37; CI&#59; 0&#46;001&#8211;0&#46;026&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41;&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0030">Conclusions</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">The increase in medication errors notified in the post-intervention period is a reflection of an increase in the motivation of health professionals to report errors through this new method&#46;</p>"
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      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0040">Objetivo</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Analizar el impacto en la notificaci&#243;n de errores de medicaci&#243;n de la puesta en marcha de un comit&#233; de seguridad multidisciplinar descentralizado en la unidad de gesti&#243;n pedi&#225;trica&#44; e implantaci&#243;n conjunta de una aplicaci&#243;n inform&#225;tica en red para la comunicaci&#243;n de errores de medicaci&#243;n&#44; mediante seguimiento de los errores y an&#225;lisis de las mejoras&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0045">Material y m&#233;todos</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Estudio observacional&#44; descriptivo&#44; transversal pre-post intervenci&#243;n&#46; Se analizan los errores de medicaci&#243;n notificados a la comisi&#243;n central de seguridad&#44; en los 12 meses previos a la implantaci&#243;n&#44; y los notificados mediante la aplicaci&#243;n inform&#225;tica descentralizada a la comisi&#243;n de seguridad de la unidad de gesti&#243;n&#44; en los 9 meses posteriores&#44; y las estrategias generadas por el an&#225;lisis&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0050">Variables medidas</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">N&#250;mero de errores notificados por 10&#46;000 d&#237;as de estancia&#44; n&#250;mero de errores con da&#241;o por 10&#46;000 d&#237;as de estancia&#44; tipo&#44; categor&#237;a en funci&#243;n de la gravedad&#44; fase del proceso&#44; colectivo que notifica y medicamentos implicados&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0055">Resultados</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Se multiplican por 4&#44;6 los errores de medicaci&#243;n notificados &#8212;7&#44;6 notificaciones por 10&#46;000 d&#237;as de estancia en el periodo preintervenci&#243;n y 36 en el postintervenci&#243;n&#8212;&#44; raz&#243;n de tasas de 0&#44;21 &#40;IC 95&#37;&#58; 0&#44;11&#8211;0&#44;39&#41; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#46;</p><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">No cambian pr&#225;cticamente los errores con da&#241;o o que necesitaron monitorizaci&#243;n notificados por 10&#46;000 d&#237;as de estancia de un periodo a otro&#44; raz&#243;n de tasas&#58; 0&#44;77 &#40;IC95&#37;&#58; 0&#44;31&#8211;1&#44;91&#41; p<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#46; Se multiplica por 17&#44;4 la notificaci&#243;n de errores sin da&#241;o o potenciales por 10&#46;000 d&#237;as de estancia&#44; raz&#243;n de tasas&#58; 0&#44;005 &#40;IC 95&#37;&#58; 0&#44;001&#8211;0&#44;026&#41; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0060">Conclusiones</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">El incremento de los errores de medicaci&#243;n notificados en el periodo postintervenci&#243;n es reflejo del aumento en la motivaci&#243;n de los profesionales sanitarios para notificar a trav&#233;s de este nuevo m&#233;todo&#46;</p>"
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      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Guerrero-Aznar MD&#44; Jim&#233;nez-Mesa E&#44; Cotrina-Luque J&#44; Villalba-Moreno A&#44; Cumplido-Corbacho R&#44; Fern&#225;ndez-Fern&#225;ndez L&#46; Validaci&#243;n en pediatr&#237;a de un m&#233;todo para notificaci&#243;n y seguimiento de errores de medicaci&#243;n&#46; An Pediatr &#40;Barc&#41;&#46; 2014&#59;81&#58;360&#8211;367&#46;</p>"
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          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Medication error categories by severity&#46; Cat A&#58; incident or circumstance that may cause harm&#59; cat B&#58; an error occurred but did not reach the patient&#59; cat C&#58; the error reached the patient&#44; but did not cause patient harm&#59; cat D&#58; the error reached the patient and did not cause patient harm&#44; but required monitoring&#47;intervention&#59; cat E&#58; error with harm&#46;</p>"
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        "mostrarFloat" => true
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        "figura" => array:1 [
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          "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Reported medication error by step of the medication process&#46;</p>"
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        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
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          "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Reported medication errors grouped by steps of medication process&#46;</p>"
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        "etiqueta" => "Figure 4"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
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          "en" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Reported causes for medication errors&#46;</p>"
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      4 => array:7 [
        "identificador" => "fig0025"
        "etiqueta" => "Figure 5"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
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        "descripcion" => array:1 [
          "en" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Number of reported errors by month in the preintervention &#40;January&#8211;December 2011&#41; and postintervention &#40;January&#8211;September 2012&#41; periods&#46;</p>"
        ]
      ]
      5 => array:7 [
        "identificador" => "tbl0010"
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        "tipo" => "MULTIMEDIATABLA"
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">G-CSF&#58; granulocyte colony stimulating factors&#59; PPIs&#58; proton pump inhibitors&#46;</p><p id="spar0100" class="elsevierStyleSimplePara elsevierViewall">Percentages of ISMP high alert drugs are presented in boldface&#46;</p><p id="spar0105" class="elsevierStyleSimplePara elsevierViewall">Source&#58; ISMP<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a>&#59; Cotrina Luque et al&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">24</span></a></p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Type of medication&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Preintervention &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>13&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Postintervention &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>42&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">Antibiotic</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">31&#37;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">29&#37;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Antifungals &#40;liposomal&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Antivirals&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Gammaglobulins&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">IV and SC insulin</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">8&#37;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">IV opioids</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">8&#37;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">Inhaled and IV general anaesthetics</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">8&#37;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">5&#37;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">Cytostatics</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">8&#37;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">31&#37;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">G-CSF&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Analgesics <span class="elsevierStyleBold">&#40;IV paracetamol&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">8&#37;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">10&#37;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">Cardiac glycosides &#40;IV inotropes&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">2&#37;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">Antiepileptics</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">2&#37;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Antiparkinsonians&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Diuretics&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">Other cardiovascular drugs&nbsp;\t\t\t\t\t\t\n
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Article information
ISSN: 23412879
Original language: English
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