Incident reporting in Mashhad hospitals

In this study, our aim was to evaluate and classify the voluntary error reports in the hospitals of Mashhad University of Medical Sciences. Patients have the right to receive health care in accordance to the best standards. Health care carries a risk of harm for patient safety, and with respect to today's stressful systems with a large number of patients, it would be inevitable. The meaning of risk management is to predict adverse events and reduce their occurrence. A voluntary medical error reporting form was designed and approved by the clinical governance team of Mashhad Medical University. They were then distributed inside hospitals in the way in which everyone [health providers and patients] could access them easily. The forms were collected and classified monthly in all wards. Classification was performed on the base of type, outcome and reporter. Data gathering took place from spring to autumn 2012. The data was analyzed by the SPSS software. 2500 errors were extracted from 1000 voluntary error reporting forms of the 12 hospitals of Mashhad Medical University. The most frequent error type was treatment errors [36%] related to drug administration, standard procedures and surgical events. Error reporting as a basic activity has an important role in discovering pitfalls of the health care system. To promote the reporting culture, its non punitive base must become clear for all professors and staff members, because this kind of reporting could lead to fewer medical errors and higher staff awareness about probable errors.

Osseous metastase of occult paraganglioma: a diagnostic medical error

Diagnostic errors have a natural complexity. Medical diagnoses make up a large proportion of all medical errors and cause much suffering and harm. Compared to other types of error, diagnostic errors receive little attention-a major factor in continuity of unacceptable rates of diagnostic error. A 55-year-old woman presented to the emergency department [ED] complaining of bone pain which has been started a month ago and increased gradually in the upper right thigh. Following the emergency evaluation she was sent home with pain medication. On the second visit, a femur neck fracture was seen in the x-ray. She underwent hemiarthroplasty and was discharged. Over several weeks she was reevaluated by many Physicians, because of her worsening pain .In the third visit after the surgery, her x-ray showed bone destruction and following bone biopsy, malignant paraganglioma was diagnosed. In all cases in which patient comes to us with skeletal pain, getting a comprehensive history and a full physical examination are prior to lab tests and x-rays. Bone metastasis which can develop severe pain and pathological fractures, is common in patients with malignant paraganglioma. Effective steps for diagnostic error prevention are: Considering the diagnostic error in the normal range of quality assurance surveillance and review, identifying the elements leading to diagnostic errors and getting feedback on the diagnoses Physicians make, in order to improve their skills. It is an every health system priority to identify, analyze, and prevent diagnostic errors in order to improve patient safety.

[Efficacy of adding cyproheptadine to risperidone in children with autistic disorder: a randomized controlled clinical trial]

The core symptoms of autism are abnormalities in social interaction, communication, and behavior. The involvement of 5-HT has been suggested in neuropsychiatric disorders and particularly in autistic disorder. The aim of this study was to assess the efficacy of cyproheptadine, a 5-HT2 antagonist, in the treatment of autistic disorder. In this double-blind, placebo-controlled trial, we assessed the effects of cyproheptadine plus risperidone in the treatment of autistic disorder.: Thirty children between the ages of 3 and 11 years [inclusive] with a DSM-IV-TR clinical diagnosis of autism referred to the child psychiatry clinics at Sheikh and Ebn-e Sina hospitals, Mashhad, were recruited. The children presented with severely disruptive symptoms related to autistic disorder. Patients were randomly allocated to cyproheptadine + risperidone [Group A; 15 patients] and risperidone + placebo [Group B; 15 patients] for an 8-week, double-blind, placebo-controlled study. The doses of risperidone and cyproheptadine were titrated up to 2 mg/day and 0.2 mg/kg/day, respectively. Patients were assessed at baseline and after 4 and 8 weeks of starting medications. The Childhood Autism Rating Scale scores after 4 and 8 weeks were 40.26 +/- 2.9 and 38.56 +/- 2.38 in group A and 40.2 +/- 3.31 and 37.73 +/- 2.59 in group B, respectively. The scores improved in both groups, but the difference between them was not significant [F=0.029, d.f= 1, p=0.867]. The results suggest that the combination of cyproheptadine with risperidone is not more effective than risperidone alone. However, the results need confirmation by a larger randomized controlled trial

[ double-blind, randomized comparison of efficacy and side effects of bupropion versus methylphenidate in children with ADHD]

ADHD is one of the most common neuropsychiatric disorders in children. Methylphenidate is the most frequent medication prescribed for this disorder, while bupropion is suggested as an alternative for treatment. This research aims to compare the efficacy and safety of bupropion and methylphenidate [Ritalin] in children with ADHD. Forty children with ADHD, aged 6 to 12 years, from consecutive referrals to child psychiatric clinic of Ibn-e-Sina hospital were selected and randomly divided into two categories [treatment with methylphenidate or bupropion]. Evaluations were carried out based on ADHD Rating Scale [by teacher and parent] and Global Clinical Scale [by clinician] at the beginning of the study and again after 4 and 8 weeks of the study. Adverse effects were also checked at 4 and 8 weeks. Data was analyzed using SPSS software, version 11.5. Data was normally distributed in the two categories in terms of demographic and quantitative variables. Therapeutic response, in parents' views, was better in Ritalin group and was significantly different at the end of the 8th week [p=0.014]. Ritalin was also more efficacious in teachers' views, but had no significant advantage [p=0.092]. Global clinical scale showed a significant advantage in both categories regarding response to therapy [p=0.014]. Therapy was seen efficacious by parents, teachers, and clinician [p < 0.001]. Results showed that bupropion was an effective agent in ADHD treatment, but its effect was less than methylphenidate based on the parents' report

Analysis of health services expenditures in Kashan province

Costs are effective on service quality and determination of total cost in health services is an important topic that always make's managers and policy makers to think about it. Usually determining the costs in health system is achieved by cross-sectional studies and this is very difficult to calculate direct and indirect costs, with the current accounting system. This study is designed and performed for determining distribution of financial resources and evaluates the current direct and indirect costs in health houses [Centers] in Kashan province. This cross-sectional and descriptive research study was conducted in 1382. Average of expenditures for each resident person in rural Health houses was 63,059 Rials [R.] With standard deviation of 38,220 R.]. The highest per capita cost was for Health house Armak [233,601 R.] and the lowest belonged to Taherabad [24,529 R.]. The annual average of direct and indirect costs of each Health house was 68967765 R., 69% direct and 31% indirect ones. 77% of direct costs and 82% of indirect costs of Health houses were personnel costs, while totally [both direct and indirect] it was 79%. Considering the average population covered by the Health house [1094 person] and large differences between the highest and lowest per capita cost of health houses according to population [209,072 R.], It seems that the services should be organized based on resident population size and suit the distribution of services by use of satellite village model and also organizational reform

[ comparison between fluoxetin and clomipramin in children and adolescents with obsessive - compulsive disorder]

Obsessive compulsive disorder [OCD] in children and adolescents is apparently a much more common disorder than what believed before. Most studies concerning treatment of OCD has been based on experience from adult patients. Only a few controlled trials using medication in children with OCD have been conducted. The present study compared the efficacy of clomipramin and fluoxetin in children and adolescents with OCD. This double blind clinical trial, performed from 2002 for one year, at Mashhad Pediatric Psychiatry, compared the efficacy of clomipramin and fluoxetin in 26 OCD children and adolescents, randomized into two groups. Efficacy assessments included the child version of Yale -Brown obsessive compulsive scale [CYBOCS] and NIMH Global rating scale and Maudsely questionnaire. The study took 8 weeks long and assessments were accomplished before the treatment, 4weeks and 8weeks after it. Clomipramin was used 10mg/day in patients over 20 kg weight and increased to 50 mg /day in one week. Dosage then rose up to 3 mg/kg based on the clinician's decision. Fluoxetin was started with 10 mg/day and reached 20 mg/day in one week. Then titrated up to 1mg/kg/day based on clinical judgment of clinician. Three patients were dropped out because of different reasons and one patient discontinued using Clomipramin because of its adverse effects. Data were collected and analyzed using the descriptive statistics and Mann withney test. There was a significant difference in the efficacy of the two drugs based on total CYBOCS score and the score of obsessions, compulsions and fluoxetine was more effective than clomipramin. However, there was no conciderable variation between them based on maudsely questionnaire, its subscales scores and NIMH Global rating scale score. The CYBOCS total score decreased to 44% and 49% after 8 weeks of clomipramin and fluoxetin consumption, respectively. The results suggested that fluoxetin is at least as effective as clomipramin in short term treatment of children and adolescents with OCD. More studies with larger sample size and longer time for follow-up are recommended

[Comparative efficacy of citalopram and nortriptyline in geriatric patients with major depressive disorder]

Major depressive disorder is a common and disabling disorder that causes high rates of morbidity and mortality. Nortriptyline is a tricyclic antidepressant that has been used for geriatric depression since a long time ago. Prescription of SSRIs in geriatric depression has been increased recently, because of more favorable profile of their side effects. This study designed to compare the efficacy of nortriptyline and citalopram in geriatric depression, Because of the importance of choosing the most appropriate medication in geriatric population. The present study was a single blind clinical trial, performed from February 2005 for a one year period. Patients age above 60 years referred to Ibne-sina hospital with the confirmed diagnosis of major depressive disorder, based on DSM-IV-TR criteria, were included in the study. These patients were randomly divided into two groups: one group [n= 37] taking citalopram 10-20 mg/day and the other group taking nortriptyline 25-150 mg/day [with the mean dose of 100 mg/day]. The efficacies of medications were assessed after 8 weeks based on the change in HDRS. Finally, 72 patients completed the study and 13 patients [5 from citalopram group, 8 from nortriptyline group], for different reasons discontinued the medication. Data analyzed using descriptive statistical tests and chi square. Demographic data and HDRS scores did not show statistical considerable variance in the two groups. Also, Changes in HRDS scores before the treatment and after 8 weeks were not significantly different between them. Insomnia was seen in 5 patients taking citalopram [13.4%]. Three patients [8.1%] in the citalopram group and one patient [2.8%] in the nortriptyline group complained from nausea in the early treatment phase. Headache was seen in 8.1% and 2.8% in the groups taking citalopram and nortriptyline, respectively. In the patients taking nortriptyline, the most prevalent complaints were dry mouth [28.5%] and drowsiness [22.8%]. Results showed that both drugs are efficient in the reduction of geriatric depressive symptoms and HRDS scores decrease was more than 50% in both groups. No significant difference was seen between the efficacy of two drugs and this result is consistent with the previous studies. These findings need to be confirmed with further researches

Depressive symptomatology in school children of Tehran - Iran [9-11 years old] and its relation to function of their families

During the past decade, as depression was becoming increasingly evident at younger ages, a great deal of attention has been directed towards the diagnosis and treatment of depression in children and adolescents. A considerable amount of research has been focused on the prevalence of depressive symptoms in children and adolescents in western societies, but researches conducted on non western samples are considerably scarce. The purposes of this study were to estimate the levels of self- reported depressive symptomatology in school children of Tehran and to assess its relationship to some characteristics of children's families. 1054 children 9-11 years of age [521 girls, 533 boys] were randomly selected frame the schools scatted in all five geographical areas of the city of Tehran. [tow schools forereach area]. Assessment of depression was undertaken as a classroom based activity with Children's Depression Inventory [CDI]. The CDI is a 27-item self- report inventory measuring depressed mood in children. All children were tested in their classrooms. Demographic and some Characteristics of their families were assessed with a questionnaire that was designed for parents of these children. With frequent contacts, 896 parents completed the questionnaires. The results of CDI and parents questionnaire were statistically 'analyzed. Considering the standard cut point of CDI [CDI score. 20], 18% of the total sample had positive test [equal to or greater than 20]. The means of the total CDI scores in boys and girls were not significantly different, but the percent of positive test were slightly higher in boys [19%] than that in girls [17%]. The means of the total children's CDI scores were significantly related to the family function in terms of emotional atmosphere of home, the number of marital conflicts and marital satisfaction of parents. In this research, school children of Tehran reported higher levels of depression than children of many western countries [10%] and these levels were comparable to results of similar researches in Russia and Egypt. The scores equal to or above the cut point in the boys were slightly more than those in the girls, which was expected in this range of age. Clearly, it is not being suggested that all children in this sample who scored equal to or above the cut point of the CDI, would meet the DSM-IV criteria for depressive disorders in terms of symptom content and severity. However the high prevalence of self-reported depression in children and the relationship between symptoms of depression and some familial variables indicate the importance of implementing preventive procedures in which these factors should be considered