Medication errors detected in elderly patients admitted to an internal medicine service.

OBJECTIVE: The aim of the work was to analyse the outpatient medication errors detected on admission in senior patients in a Spanish general internal medicine service. PATIENTS AND METHODS: We carried out a retrospective cohort study based on a review of the admission reports of consecutive, non-selected, patients aged ≥ 65 years. RESULTS: Eight hundred and sixty admission reports (cases) were analysed. Overall, we detected 218 errors in 173 (20.1%) of them. 'Wrong drug' errors were found in 165 occasions (75.7% of the 218 detected errors), being the most frequent among these 'not indicated/inappropriate drug for the diagnosis' (61 cases, 28.0%), followed by 'not indicated/inappropriate drug for the patient's condition' (55 cases, 25.2%). The binary logistic regression analysis showed association (p<0.05) between medication errors and sex (female) (OR 0.53, 95%, CI 0.37-0.76), cognitive impairment (OR 0.57, 95% CI 0.38-0.85), length of hospital stay (OR 1.06, 95% CI 1.00-1.11), number of diagnoses (OR 0.92, 95% CI 0.85-0.98), number of medicines at admission (OR 1.20, 95% CI 1.13-1.28) and lack of a recent previous admission in an internal medicine department (OR 2.07, 95% CI 1.14-3.74). CONCLUSION: Although previous studies are not completely comparable, the incidence of errors found at admission in our study is low. We stress the relevance of the reconciliation of treatment in elderly people (where internists may play an important role, from their perspective of a comprehensive patient's care) and integrated procedures for medication prescription and dispensation.

[Monitoring of a protocol for the adequacy of the pharmaceutical form of the oral medication to the degree of dysphagia in patients hospitalized in an internal medicine service]. / Pilotaje de un protocolo para la adecuación de la forma farmacéutica de la medicación oral al grado de disfagia, de los pacientes ingresados en un servicio de medicina interna.

INTRODUCTION: The oral route is the most convenient way of administering medication, although it may not be safe. Dysphagia is one of the factors rendering difficult a proper feeding and administration of medication. OBJECTIVES: to improve the administration of oral medication in patients with dysphagia by changing the pharmaceutical formulation of the principles prescribed to tolerable textures. METHODS: Pilot project for the application of a dysphagia protocol that included the patients admitted to the Internal Medicine Unit at Los Montalvos Center for 4 months. After detecting the suspicion of dysphagia, a dysphagia-viscosity test was applied to know the tolerated textures. Then, the pharmaceutical formulations were adapted and the manipulation instructions for the drugs were indicated for their proper administration. RESULTS: 23 out of 627 admitted patients were included, with a mean age of 85 years (σ±7.4). The pathologies implicated in dysphagia were: dementia (65.2%); cerebrovascular disease (30.4%), and Parkinson's disease (4.4%). The best texture for drug intake was a "pudding" in 48.0%. 43 active ingredients were reviewed and 134 interventions were performed: in 41% of the cases, swallowing was made easier by mixing the drug with the food and in 59% water and a thickener were used. 94% of the recommendations were considered to be appropriate. CONCLUSION: the adaptation of the pharmaceutical formulations to the degree of dysphagia impacts on the improvement of healthcare quality by implementing safety in drug prescription and administration processes.

Calidad percibida por los usuarios de un servicio de Medicina Interna tras 5 años de aplicación de una encuesta de satisfacción / User's perceived quality in an internal medicine service after a five-year period application of a user's satisfaction survey

ObjetivoValorar la calidad percibida por los usuarios del Servicio de Medicina Interna de Los Montalvos (Salamanca) durante los 5 primeros años de funcionamiento de este.Material y métodosEstudio transversal, realizado desde febrero de 2004 hasta enero de 2009. A todos los pacientes hospitalizados (6.997) se les entregó al alta una encuesta modelo SERVQHOS de cumplimentación anónima y voluntaria.ResultadosSe recogieron 2.435 encuestas. La participación fue del 34,8%. Excepto en lo relativo a la accesibilidad, las cuestiones planteadas en la encuesta se percibieron como se esperaba o por encima de las expectativas por parte de más del 85% de los encuestados. El 90,6% de los pacientes estuvo satisfecho con la atención recibida y el 83,9% recomendaría el hospital a otras personas. Las variables con mayor capacidad predictiva, en relación con la satisfacción global, fueron el trato personalizado y el interés del personal por solucionar problemas. El 33,6% valoró la facilidad para llegar al hospital por debajo de lo esperado. Tras implantar medidas de mejora, el porcentaje de insatisfacción respecto a la accesibilidad se situó en el 24,8% (p=0,02).ConclusionesNueve de cada 10 pacientes encuestados estaban satisfechos o muy satisfechos con la atención recibida y recomendarían el hospital a otras personas. Las variables más vinculadas con la satisfacción global fueron las relacionadas con el personal del servicio. Tras detectar deficiencias e implantar medidas de mejora, la encuesta detectó mejoría en el nivel de satisfacción(AU9

ObjectiveTo evaluate the quality perceived by users of the ‘Los Montalvos’ Internal Medicine Service (Salamanca, Spain), over its first five years of operation.MethodsA cross-sectional study was carried out from February 2004 to January 2009. All in-patients (6,997) were given a survey model SERVQHOS at the time of discharge, which was anonymous and voluntary.ResultsWe collected 2,435 surveys. Participation was 34.8%. Except for the item regarding accessibility, the other questions of the survey were perceived “as expected” or above expectations by over 85% of the users. A total of 90.6% of patients who completed the survey were satisfied with the care received, and 83.9% would recommend the hospital to others. The variables with higher predictive capability, in relation to overall satisfaction, were “personalised care’, and the interests of staff to solve problems. The easy access to the hospital’ was seen by 33.6% as below expectations. After introducing several improvement measures, the percentage of dissatisfaction regarding accessibility was 24.8% (p=0.02).ConclusionsNine out of ten patients surveyed were satisfied or very satisfied with the care received, and would recommend the hospital to others. The variables more strongly associated with overall satisfaction were those related to service personnel. After identifying deficiencies and implementing measures to improve, the survey detected an increase in the level of satisfaction(AU)

[User's perceived quality in an internal medicine service after a five-year period application of a user's satisfaction survey]. / Calidad percibida por los usuarios de un servicio de Medicina Interna tras 5 años de aplicación de una encuesta de satisfacción.

OBJECTIVE: To evaluate the quality perceived by users of the 'Los Montalvos' Internal Medicine Service (Salamanca, Spain), over its first five years of operation. METHODS: A cross-sectional study was carried out from February 2004 to January 2009. All in-patients (6,997) were given a survey model SERVQHOS at the time of discharge, which was anonymous and voluntary. RESULTS: We collected 2,435 surveys. Participation was 34.8%. Except for the item regarding accessibility, the other questions of the survey were perceived "as expected" or above expectations by over 85% of the users. A total of 90.6% of patients who completed the survey were satisfied with the care received, and 83.9% would recommend the hospital to others. The variables with higher predictive capability, in relation to overall satisfaction, were "personalised care', and the interests of staff to solve problems. The easy access to the hospital' was seen by 33.6% as below expectations. After introducing several improvement measures, the percentage of dissatisfaction regarding accessibility was 24.8% (p=0.02). CONCLUSIONS: Nine out of ten patients surveyed were satisfied or very satisfied with the care received, and would recommend the hospital to others. The variables more strongly associated with overall satisfaction were those related to service personnel. After identifying deficiencies and implementing measures to improve, the survey detected an increase in the level of satisfaction.

[Elderly population and campaigns for the prevention of hypercholesterolemia in Salamanca]. / Población anciana y campañas para la prevención de la hipercolesterolemia en Salamanca.

OBJECTIVE: To analyze the cardiovascular risk profile of the persons older than 65 years of age who participated in different "Days on Cholesterol and Atherosclerosis" organized during 1999 in different towns of the province of Salamanca. MATERIAL AND METHODS: The volunteers of any age were subjected to a questionnaire and to several clinical and laboratory measurements. RESULTS: The age of 267 volunteers (40.8% males) attending the campaign was > or = 65 years. The mean values of the studied parameters were: age = 72.3 +/- 6.5 years; body mass index (BMI) = 26.8 +/- 4.5 kg/m2; systolic blood pressure (SBP) = 139.8 +/- 20.6 mmHg; dystolic blood pressure (DBP) = 80.0 +/- 10.1 mmHg; and total cholesterol (TC) = 226.2 +/- 44.9 mg/dl. The percentage of smoking habit was 5.2%. The figures of SBP showed positive significant correlation with those of age (p < 0.05) and DBP (p < 0.01). Among males, the age evolved inversely to the numbers of TC (p < 0.01). Globally, 203 volunteers (76.0%) had concentrations of TC > or = 200 mg/dl; 78 (29.2%) > or = 250 mg/dl; and 12 (4.5%) concentrations > or = 300 mg/dl. We detected blood pressure levels of SBP > or = 140 mmHg in 143 (53.6%) individuals; SBP > or = 180 mmHg in 11 (4.1%); DBP > or = 90 mmHg in 72 (27.0%); and DBP > or = 110 mmHg in 4 (1.5%). The BMI was > or = 30 kg/m2 in 54 (20.2%) people of the study. 90.8% of the volunteers with previous cardiovascular disease carried, at least, another not controlled cardiovascular risk factor; 24.1% had at least two risk factors; and 9.1% had, at least, three. In 38.5% they showed high levels of TC and DBP, simultaneously. CONCLUSIONS: Our data, together with the current evidences about the benefit of the control of cardiovascular risk factors in the elderly, suggest the necessity to establish strategies for a better control of the cardiovascular risk in this group of age in our province.

Antigens of Rickettsia conorii recognized by seropositive healthy people from Salamanca (central-west Spain).

The antigenic reactivity in Western immunoblotting assay of individual Rickettsia conorii components with sera of healthy people living in Salamanca Province, an endemic zone of Mediterranean spotted fever, is evaluated. Polypeptides of molecular weights 100 kDa (92.7%), 135 kDa (75.6%), 160 kDa (70.7%) and 115 kDa (48.8%) were recognized by a higher proportion of sera with indirect immunofluorescent antibody test titers > or = 1:80. Reaction with apparent rickettsial lipopolysaccharide was found in 15 (36.6%) of these samples. The involvement of different rickettsial strains, atypical routes of inoculation, varying content of the inoculum, and host factors may be determinants of the clinical expression of the spotted fever group rickettsial infection in people who produce antibodies reactive with Rickettsia conorii antigens.

Use of western blot to analyze the reactivity of sera from patients with Mediterranean spotted fever.

The reactivity of antigenic components of Rickettsia conorii with sequentially obtained sera from 20 adult Spanish patients with Mediterranean spotted fever was analyzed by Western blot. The major rickettsial antigens reacting with the serum samples corresponded to molecular weights of 135 and 115 kDa. These antigens constantly exhibited higher staining intensity than the other antigens, and reacted with 100% and 86.7%, respectively, of acute sera and with 100% of convalescent phase samples. Rickettsial lipopolysaccharide antigens reacted with 94.7% of sera collected in the fourth and fifth week after onset of symptoms. Other major antigens reactive in the blots had molecular sizes of 160, 100, 90 and 60 kDa, and a relatively frequent humoral immune response was also seen to antigens of 80, 73 and 55 kDa.

Evaluation of ciprofloxacin and doxycycline in the treatment of Mediterranean spotted fever.

A comparison was made of the results obtained with ciprofloxacin (750 mg/12 h) and doxycycline (100 mg/12 h), both administered p.o. for one week, in 34 and 36 patients respectively with Mediterranean spotted fever. Apyrexia was achieved after 50.1 +/- 34.2 h (mean +/- SD) of antibiotic therapy in the group of patients treated with ciprofloxacin and in 55.2 +/- 23.3 h in the group treated with doxycycline (no significant statistical differences). Resolution of the remaining signs and symptoms of the disease was achieved faster with ciprofloxacin. Both therapeutic regimens were effective and safe. Although more expensive than doxycycline, ciprofloxacin is a bactericidal compound which is better tolerated and has a lower risk of toxicity and of development of resistance. It can be considered, together with doxycycline, as an antibiotic of first choice in the treatment of Mediterranean spotted fever.

Role of Lagomorpha in the wild cycle of Rickettsia conorii in Salamanca (Spain).

In an endemic zone for Mediterranean spotted fever levels of antibodies to R. conorii were evaluated in serum samples from wild rabbits (Orytolagus cuniculus) and hares (Lepus granatensis) using an indirect microimmunofluorescence antibody test. The results of the study show that the wild rabbit may carry out in this area an important function in the maintenance of R. conorii in nature.

Mechanism of low serum sodium levels in Mediterranean spotted fever.

Prominent degrees of hyponatremia are detected in the severe forms of Mediterranean spotted fever and the intensity of this abnormality parallels the severity of the infectious process. In order to determine the incidence, degree and evolution of hyponatremia in 110 patients with Mediterranean spotted fever and to explore the feasible renal mechanism that could lead to this phenomenon, serum and urinary osmolality and levels of urea, creatinine and electrolytes were measured in samples obtained at selected points (up to the fifth week) in the course of the disease, and parameters of renal function were calculated. Mean serum sodium levels of 135.6 +/- 5.5 mEq/l were detected during the acute phase of the infection. At this point, 42 patients (38.2%) had sodium concentrations less than or equal to 135 mEq/l. After recovery, mean serum sodium values were 142.5 +/- 2.5. The analysis of the parameters of renal function indirectly rules out an inappropriate antidiuretic hormone secretion or renal failure as the cause of hyponatremia. As tubular incompetence to reabsorb sodium is also rejected in these patients, a shifting of sodium to the interstitial or intracellular space may account for the phenomenon.

Prevalence of antibodies to Rickettsia conorii Coxiella burnetii and Rickettsia typhi in Salamanca Province (Spain). Serosurvey in the human population.

The Salamanca Province of Spain is an endemic zone for Mediterranean spotted fever. In this area, only one case of Q fever has been reported and typhus group rickettsial diseases have never been diagnosed. To obtain a panoramic view of the presence of antibodies to the most ubiquitous rickettsial agents, 400 sera specimens from a statistically representative sample of the human population of Salamanca City and its surrounding province were subjected to indirect microimmunofluorescent test for antibodies against Rickettsia conorii, Coxiella burnetti, phase II, and Rickettsia typhi antigens. Titers greater than or equal to 1:40 to R. conorii were found in 73.5% of the sera. Positivity was more common in subjects who reported closer contact with the natural environment and/or with domestic animals. Seropositivity to C. burnetti, phase II, was detected in 50.2% of sera. These positive cases were related to rural environmental factors and to previous contact with animals. The frequency of antibodies increased with age showing a progressive exposure to the rickettsial antigen. The prevalence of antibodies to R. conorii and C. burnetii in the human population of Salamanca Province is higher than that reported from any other geographic zone. The study of antibodies to R. typhi showed that 12.5% of the sera had titers greater than or equal to 1:40. According to our results, seropositivity to this rickettsial antigen cannot be related to any particular group of population nor interpreted totally as cross reactivity with R. conorii. Our data show a wide distribution of R. conorii and C. burnetii antigens in Salamanca Province, and also indicate the presence of R. typhi antigens in this area.

[Immunohistochemical diagnosis of Mediterranean spotted fever: detection of rickettsial antigens in the initial skin lesions]. / Diagnóstico inmunohistoquímico de la fiebre exantemática mediterránea: detección de antígenos rickettsiales en las lesiones cutáneas de puerta de entrada.

In eight patients with Mediterranean spotted fever we evaluated the yield of the direct immunofluorescence technique against rickettsial antigens for the early laboratory diagnosis of the disease. Frozen sections of biopsy specimens of the initial lesion (tache noire) taken on the admission day were processed by a fluorescent conjugate reactive against Rickettsia conorii. In seven cases, coccobacillary formations consistent with rickettsiae were observed in the studied specimens. The results were negative in the controls and in three of six samples of exanthema elements obtained from six simultaneously studied patients with Mediterranean spotted fever. Our data demonstrate the diagnostic value of direct immunofluorescence applied on the tache noire. This technique is particularly useful in the initial stages of the disease, before the clinical and serological features have completely developed.

Mechanism of upper gastrointestinal hemorrhage in Mediterranean spotted fever.

Gastrointestinal (GI) hemorrhage is not a common complication of Mediterranean spotted fever (MSF). We describe three MSF cases with upper digestive tract bleeding in patients from Salamanca (Spain) and the results of the histologic studies performed in two of them. Besides the classical clinical triad of the disease (fever, rash and lesion at the site of tick bite, 'tache noire'), these patients presented purpuric rash and hypoalbuminemia, previously identified in severe forms of the disease. The hemorrhagic complication occurred late in the course of the MSF (between 13 and 20 days after the onset of fever) and was the consequence of multiple acute superficial erosions of the gastric mucosa. The histologic substrate of these lesions was identified as a vasculitic process - characteristically lymphohistiocytic - affecting the small vessels of the gastric wall. Rickettsial vascular injury at this level of the digestive tract is histologically similar to that observed in other organs in patients with MSF and may manifest clinically as digestive tract bleeding.

Mediterranean spotted fever in Salamanca, Spain. Epidemiological study in patients and serosurvey in animals and healthy human population.

Mediterranean spotted fever is a spotted fever group rickettsiosis caused by Rickettsia conorii. The fever has a recognized incidence in large geographic areas, and its presence in Salamanca Province (Spain) has been well documented since 1981. This work presents the results of the centralized prospective survey carried out in this area and was designed to study the epidemiological behavior of the disease and the prevalence of antibodies against R. conorii among animals and healthy human population. In 110 patients with confirmed diagnosis by an immunofluorescent antibody test we have observed a bimodal temporal curve of incidence of Mediterranean spotted fever in our zone and their predominant origin in villages under 2000 inhabitants. The serosurvey in a statistically representative sample of the human population of Salamanca shows a rate of 73.5% of reactive sera and percentages as high as 82% in samples from small villages. The seroepidemiological study of 300 animals reveals a widespread response to rickettsial antigens throughout the province. Immunofluorescent antibody titers of greater than or equal to 1:40 are present in 93% of dogs and high rates and titers are detected in other domestic mammals, suggesting their feasible epidemiological role in Mediterranean spotted fever.