Analysis of contributing factors associated to related patients safety incidents in Intensive Care Medicine

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García del Águila, J. López-Messa, F. Rosell-Ortiz, R. de Elías Hernández, M. Martínez del Valle, L. Sánchez-Santos, J. López-Herce, M. Cerdà-Vila, C.L. Roza-Alonso, M. Bernardez-Otero" "autores" => array:13 [ 0 => array:2 [ "nombre" => "J." "apellidos" => "García del Águila" ] 1 => array:2 [ "nombre" => "J." "apellidos" => "López-Messa" ] 2 => array:2 [ "nombre" => "F." "apellidos" => "Rosell-Ortiz" ] 3 => array:2 [ "nombre" => "R." "apellidos" => "de Elías Hernández" ] 4 => array:2 [ "nombre" => "M." "apellidos" => "Martínez del Valle" ] 5 => array:2 [ "nombre" => "L." "apellidos" => "Sánchez-Santos" ] 6 => array:2 [ "nombre" => "J." "apellidos" => "López-Herce" ] 7 => array:2 [ "nombre" => "M." "apellidos" => "Cerdà-Vila" ] 8 => array:2 [ "nombre" => "C.L." "apellidos" => "Roza-Alonso" ] 9 => array:2 [ "nombre" => "M." 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Martín Delgado, P. Merino de Cos, G. Sirgo Rodríguez, J. Álvarez Rodríguez, I. Gutiérrez Cía, B. Obón Azuara, Á. Alonso Ovies" "autores" => array:8 [ 0 => array:4 [ "nombre" => "M.C." "apellidos" => "Martín Delgado" "email" => array:1 [ 0 => "mmartin@torrejonsalud.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "P." "apellidos" => "Merino de Cos" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "G." "apellidos" => "Sirgo Rodríguez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "c" "identificador" => "aff0015" ] ] ] 3 => array:3 [ "nombre" => "J." "apellidos" => "Álvarez Rodríguez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "d" "identificador" => "aff0020" ] ] ] 4 => array:3 [ "nombre" => "I." 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"apellidos" => "Alonso Ovies" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "d" "identificador" => "aff0020" ] ] ] 7 => array:1 [ "colaborador" => "Grupo SYREC" ] ] "afiliaciones" => array:6 [ 0 => array:3 [ "entidad" => "Servicio de Medicina Intensiva, Hospital Universitario de Torrejón, Torrejón de Ardoz, Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Medicina Intensiva, Hospital Can Misses, Ibiza, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Unidad de Cuidados Intensivos, Hospital Universitario Joan XXIII, Instituto de Investigación Sanitaria Pere Virgili, Universidad Rovira i Virgili, Tarragona, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Servicio de Medicina Intensiva, Hospital Universitario de Fuenlabrada, Fuenlabrada, Madrid, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Servicio de Medicina Intensiva, Hospital Clínico Universitario, Zaragoza, Spain" "etiqueta" => "e" "identificador" => "aff0025" ] 5 => array:3 [ "entidad" => "Servicio de Medicina Preventiva y Salud Pública, Hospital Clínico Universitario, Zaragoza, Spain" "etiqueta" => "f" "identificador" => "aff0030" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Análisis de los factores contribuyentes en incidentes relacionados con la seguridad del paciente en Medicina Intensiva" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1685 "Ancho" => 2374 "Tamanyo" => 256961 ] ] "descripcion" => array:1 [ "en" => "Distribution of contributing factors according to class and type of incidents." ] ] ] "textoCompleto" => "IntroductionThe critical patient care environment is extremely complex. In Departments of Intensive Care Medicine (DICMs), factors such as the seriousness of the patient condition, the communication barriers, the invasive therapeutic and diagnostic procedures used,<a class="elsevierStyleCrossRef" href="#bib0160">1</a> and the volume of information managed all contribute to the appearance of incidents related to patient safety.<a class="elsevierStyleCrossRef" href="#bib0165">2</a>Although not all healthcare related incidents that occur in the DICM actually affect the patients, some of them can cause temporary damage requiring additional observation and care, prolonging hospital stay and–in some cases–causing permanent damage or even death.<a class="elsevierStyleCrossRef" href="#bib0170">3</a>Two aspects must be underscored in this regard. Firstly, most incidents detected in the DICM are avoidable.<a class="elsevierStyleCrossRef" href="#bib0175">4</a> Secondly, although errors can occur in all areas of the hospital, patients admitted to the DICM are more vulnerable, and the consequences are more serious.<a class="elsevierStyleCrossRefs" href="#bib0180">5,6</a>In the patient safety context, it is admitted that most incidents related to medical care are a consequence of active error on the part of the professionals, favored by factors latent within the system. The analysis of these factors, applied to clinical safety, has been carried out based on the results of safety analyses in other fields such as aviation.<a class="elsevierStyleCrossRef" href="#bib0190">7</a>A modern approach by those institutions that aim to effectively address patient safety with the purpose of reducing the number of incidents related to medical care inevitably includes knowledge of the causes underlying such incidents and their contributing factors (CFs).<a class="elsevierStyleCrossRef" href="#bib0195">8</a> Furthermore, in-depth knowledge of these factors makes it possible to distinguish between those that influence an isolated incident and those which are common to incidents within a certain institution or Department.<a class="elsevierStyleCrossRef" href="#bib0200">9</a>The systematic classification of CFs and their analysis should allow the development of strategies for improving the defenses and failures of the system. In Spain there is no exhaustive information on incidents related to medical care in the critical care setting, and the lack of data is even more manifest when considering the factors related to the appearance of such incidents.<a class="elsevierStyleCrossRef" href="#bib0205">10</a> For this reason, a collaborative agreement was established between the Spanish Ministry of Health and the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias, SEMICYUC) to conduct the multicenter Safety and Risk in the Critical Patient (Seguridad y Riesgo en el Enfermo Crítico, SYREC) study–the main objective of which was to estimate the incidence of adverse events (AEs) and near-miss incidents (NMIs) in the Intensive Care setting, classify them, and assess their impact and avoidability.<a class="elsevierStyleCrossRef" href="#bib0210">11</a> The results of this study have recently been published.<a class="elsevierStyleCrossRef" href="#bib0175">4</a>The present study analyzes the factors that contribute to the appearance of NMIs and AEs in the critical patient, and explores their relation to the class, severity and avoidability of incidents related to medical care, based on the results of the SYREC study.Material and methodsDesign: A post hoc analysis was made of the SYREC study (a multicenter, prospective cohort observational study with a follow-up duration of 24h, conducted in the DICM).Inclusion criteria: All patients admitted to the participating DICMs during the observation period. The subjects who were admitted, were discharged, or who died during the study period were included.Endpoints and measures:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">a)Primary (reported CFs): we analyzed the frequency, incidence and type of CF. Categorization of the CFs was based on an adaptation of the model proposed by the National Patient Safety Agency (NPSA) of the United Kingdom.<a class="elsevierStyleCrossRef" href="#bib0215">12</a> The CFs were classified into 8 groups: individual factors of the professional, team and social factors, communication factors, task related factors, equipment and resource related factors, working conditions, patient factors, and training and educational factors. Each group of CFs in turn could comprise one or more subfactors. For each reported patient safety related incident (PSRI), the notifier could consider one or more groups of CFs and, within each group, one or more related subfactors.</li><li class="elsevierStyleListItem" id="lsti0010">b)Secondary (classes of incidents related to medical care): we included NMIs and AEs occurring, detected and reported during the observation period in the Unit, as well as those occurring outside the Unit but which were the reason for admission to the latter. Near-miss incidents were defined as incidents causing no patient damage, either because they fail to actually reach the patient, or because they produce no consequences even if they do reach the patient. Adverse events in turn were defined as unforeseen and unexpected incidents reported by the professionals and which cause damage, disability or prolongation of stay, or death as a consequence of medical care and which are unrelated to the evolution or possible complications of the patient background disease.</li></ul>Class of incident (classification adopted by the authors based on the literature): The incidents were divided into in 11 classes: (1) medication; (2) blood and blood product transfusions; (3) airway and mechanical ventilation; (4) vascular accesses, catheters, tubes, drains and sensors; (5) medical equipment and system failure; (6) diagnostic error; (7) diagnostic tests; (8) nursing care; (9) procedures; (10) nosocomial infection; and (11) surgery related incidents.Severity of the incident: This was analyzed based on an adaptation of the classification of medication errors of the Ruiz-Jarabo group.<a class="elsevierStyleCrossRef" href="#bib0220">13</a> The changes affected categories A and B, which were merged. A new category (category D) was added, due to the difficulty in many cases of assessing the consequences of the incident (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Avoidability of the incident: The NMIs and AEs were classified as follows according to the criterion of the observer: undoubtedly avoidable, possibly avoidable, possibly unavoidable or unavoidable.Procedure: All the DICMs in Spain (a total of 220) were invited to participate through the SEMICYUC website, e-mail or conventional mail. A total of 79 DICMs finally agreed to participate. After confirming acceptance, each Unit assigned two coordinators (a physician and a nurse), who in turn received a document describing the study design and providing instructions to standardize the inclusion criteria and data collection. Supportive and training material was also made available to all the professionals in the Units, before the start of the study.A questionnaire distributed in paper format was used for data collection. On the day of the study, all the physicians, nurses and assistant personnel completed the corresponding questionnaires on a voluntary and anonymous basis. The coordinators in each center checked correct completion of the questionnaires, entered the data in an electronic format and forwarded them by e-mail to the principal investigators of the study.Data collection quality control: All the reported incidents were individually reviewed by the principal investigators of the study. A consensus meeting was subsequently held to examine the discrepancies and decide whether to include or exclude them, and to reclassify those incidents which were considered to be incorrectly classified.Statistical analysis: A descriptive analysis was made of all the variables included in the study. Qualitative variables were reported as frequency distributions, while quantitative variables were presented using the mean and standard deviation (SD) as dispersion measures, or the median and interquartile range (IQR) in the event of an asymmetric distribution. In the bivariate analysis, the possible association between quantitative variables was evaluated using the chi-squared test. The comparison of means for two independent samples in turn was carried out using the Student t-test for independent samples, with analysis of variance (ANOVA) in the case of more than two means–in both cases considering a symmetric (normal) sample distribution as established by the homogeneity of variance analysis. In the case of an asymmetric distribution, we used the median test for the contrasting of hypotheses. The data were entered in a MS Access database, followed by statistical processing with the SPSS version 19.0 statistical package.Confidentiality and ethical considerations: Since this was an observational study involving no interventions of any kind, the obtainment of informed consent was not considered necessary. The study was approved by the Clinical Research Ethics Committee (CREC) of Aragon. Each DICM agreed to obtain the required permissions at local level. In accordance with Act 15/1999 referring to the protection of personal data,<a class="elsevierStyleCrossRef" href="#bib0225">14</a> and with Act 41/2002, of 14 November, regulating patient autonomy and rights and obligations in relation to clinical documentation and information,<a class="elsevierStyleCrossRef" href="#bib0230">15</a> the anonymity of the patients and of the personnel involved in the incidents was ensured in the collected and submitted data. The results of this study were not directly binding for either the professionals or the patients, and the decision was made to publish both the positive and the negative findings.ResultsA total of 79 DICMs belonging to 76 hospitals participated in the study, with the inclusion of 1017 patients. At least one incident was reported in 591 of these patients (58%). During the study period a total of 1424 patient safety related incidents (PSRIs) were reported: 943 NMIs (66%) and 481 AEs (44%). One or more contributing factors (CFs) were reported in 1247 PSRIs (87.57%).Reported contributing factorsA total of 2965 CFs were documented, of which 1729 (58.31%) were reported in relation to 943 NMIs and 1236 (41.69%) in relation to 481 AEs–this representing a median of one CF per NMI (IQR 1–2) and of two CFs per AE (IQR 1–3)(p < 0.001). No CFs was reported in 12.7% of the NMIs and in 11.9% of the AEs.The most frequently reported CFs corresponded to patient related factors (21.9%), followed by the working conditions (19.9%), and individual factors of the professional (19.4%). <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> describes the frequencies with which the different groups of CFs were reported. The table also describes the most common subfactors cited in each group of CFs and their main characteristics. It should be noted that complexity and severity were the factors most often cited in the group of patient related factors.<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>Reported contributing factors according to the types of patient safety related incidentsThe groups of CFs corresponding to equipment and resources, communication and individual professional factors were more frequently reported in NMIs (82.9%, 80.7% and 79.4%, respectively). In contrast, the groups of CFs related to patient, task and training and education were more frequently reported in AEs (69.6%, 57.4% and 43.6%, respectively) (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).Reported contributing factors according to the classes of patient safety related incidentsIncidents corresponding to all 11 of the considered classes were reported. The class of incidents with the greatest percentage of reported CFs corresponded to diagnostic error (93.7%; 16 incidents related to medical care, and only one incident with no CF) and surgery (93.6%; 47 incidents related to medical care, only 3 incidents with no CF). In contrast, the class of incidents with the lowest percentage of reported CFs corresponded to transfusion (80%). However, it must be noted that only 5 incidents were documented in this class.<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> describes the classes of incidents related to each group of CFs. Within the group of CFs related to the patient, the most common incidents corresponded to surgery. In contrast, the working conditions and individual factors of the professional were more often associated to transfusion and medication incidents.On the other hand, <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a> summarizes the distribution of the reported CFs according to the class and type of incident involved. Of note is the fact that all reported CFs referred to transfusion corresponded to NMIs. In contrast, 97.9% of the CFs reported in the context of surgical incidents corresponded to AEs.<elsevierMultimedia ident="fig0005"></elsevierMultimedia>Groups of contributing factors in relation to the reporting professionalOf the 2965 documented CFs, 1627 were reported by nursing personnel, 896 by staff physicians, 259 by residents in training, 156 by nursing assistants, and 27 by other professionals. In general, physicians were the most frequent reporters of patient related factors (32.1%) and, in contrast, the least frequent reporters of individual factors of the professional (11.4%) and factors related to equipment and resources (3.3%). On the other hand, residents in training were the professionals who reported the fewest incidents involving CFs related to working conditions (10.4%). <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a> shows the number of CFs reported according to groups of factors and the reporting persons.<elsevierMultimedia ident="tbl0015"></elsevierMultimedia>Groups of contributing factors in relation to the severity of the incidentMost of the CFs (2011; 67.8%) corresponded to incidents classified as being less serious (categories A and D), while 954 (32; 2%) corresponded to more serious incidents (categories E-I). The group of CFs related to greatest severity of the PSRIs corresponded to patient related factors.Groups of contributing factors in relation to the avoidability of the incidentA total of 2535 CFs corresponded to 1136 incidents related to patient safety classified as “undoubtedly avoidable” or “possibly avoidable”, while 430 CFs corresponded to 288 incidents classified as “possibly unavoidable” or “unavoidable”. <a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a> shows the distribution of reported CFs by groups and according to the avoidability of the incident. The individual factors of the professional and factors related to the working conditions were associated to avoidable PSRIs. In contrast, the CFs related to the patient and equipment and resources were associated to unavoidable PSRIs.<elsevierMultimedia ident="tbl0020"></elsevierMultimedia>DiscussionThe contributing factors (CFs) that intervene in the appearance of patient safety related incidents (PSRIs) have been little investigated in the Intensive Care setting. To date, and from outside the context of critical care, the different publications have attempted to investigate CFs through retrospective studies<a class="elsevierStyleCrossRefs" href="#bib0235">16–19</a> or based on reporting systems.<a class="elsevierStyleCrossRefs" href="#bib0255">20–23</a> More recently, studies from the perspective of medicine based on evidence have attempted to structure CFs into groups that can help us understand the appearance of PSRIs.<a class="elsevierStyleCrossRef" href="#bib0275">24</a> In this regard, Lawton et al. identified active errors (failure to adhere to norms and protocols), together with factors related to the individual (knowledge and experience), and communication deficiencies, as the groups of CFs most frequently implicated in the appearance of PSRIs. The same authors also underscored a weakness that can be extended to any study that obtains information through reporting: the reporting professional is probably not an expert in safety matters, and is only able to point to the causes closest to the incident.In our study, based on voluntary reporting encouraged by the coordinators, the most frequently reported CFs were those related to the patient. This is not surprising, since critically ill patients are particularly vulnerable to PSRIs because of the inherent seriousness of their condition. The second most frequently reported CFs corresponded to the working conditions. In this regard, Sanghera et al.<a class="elsevierStyleCrossRef" href="#bib0280">25</a> pointed to the working conditions as the main CFs associated to medication error in critical patients, followed by communication related factors.The data contained in the literature are heterogeneous. As an example, studies based on systems for reporting incidents in DICMs have found the most frequently reported CFs to be human factors, followed by systemic factors such as the working conditions, equipment and communication, among others.<a class="elsevierStyleCrossRef" href="#bib0285">26</a> On the other hand, and likewise based on a multicenter reporting system in different North American DICMs, Holzmueller et al.<a class="elsevierStyleCrossRef" href="#bib0290">27</a> found the CFs most frequently associated to PSRIs to be related to training and education, followed by communication related factors. Probably one of the elements that explain the lack of concordance in relation to the reported CFs is the methodology used in detecting the incidents, which can give rise to different interpretations regarding the CFs.<a class="elsevierStyleCrossRef" href="#bib0285">26</a>We consider a number of the findings of our study to be of interest. On one hand, the number of CFs reported in AEs was greater than in NMIs. Although the causal mechanism underlying incidents with and without damage or injury is similar, professionals identify more CFs when the patient experiences damage. This may be because the search to identify what has happened is more intense when damage in the form of an AE has effectively occurred.<a class="elsevierStyleCrossRef" href="#bib0200">9</a> On the other hand, it should be mentioned that the reported CFs differ when separately considering NMIs and AEs. Among the former, the most frequently reported CFs corresponded to individual factors of the professional, followed by communication factors. In contrast, on considering AEs, the most frequently reported CFs were seen to be related to the task and to the patient. It should be noted that the group of CFs related to the task includes aspects as important as the lack of specific protocols or failure to adhere to the existing protocols. The former problem is relatively easy to solve by developing the necessary protocols, while the latter (failure to adhere to the existing protocols or even to internationally accepted treatment guides) is the subject of continuous analysis.<a class="elsevierStyleCrossRefs" href="#bib0295">28,29</a>Another aspect that should be commented is the correlation of the CFs to the class of PSRI. In this regard, patient related factors–which generally speaking were the most frequently cited CFs–were associated to surgery related incidents. This may be because surgical procedures are typically performed in seriously ill patients. In turn, professional factors, which were the most commonly reported CFs in NMIs, were associated to medication error. Lastly, task related factors, which were the most commonly reported CFs in AEs, were associated to nosocomial infection. This circumstance again points to error of omission (failure to adhere to the clinical practice guides) as possibly being the cause of AEs as sensitive as infection associated to medical care.<a class="elsevierStyleCrossRef" href="#bib0305">30</a>In relation to avoidability, most of the incidents were classified as avoidable, in coincidence with the observations of other authors.<a class="elsevierStyleCrossRef" href="#bib0250">19</a> The groups of CFs related to avoidable PSRIs were individual factors of the professional, followed by equipment related factors. In contrast, the unavoidable incidents were fundamentally associated to patient related factors.This study has some limitations. On one hand, in relation to the methodology used, the incidents were recorded by professionals working in the DICMs. Although these professionals had received basic information on patient safety, they cannot be regarded as experts in this field–a fact that limits the detection of CFs. At the same time, although reporting by the professionals can allow the identification of CFs that are not easy to identify with other methods (e.g., case history reviews), it may limit assessment of the CFs by not offering a true root cause analysis. Given the voluntary and anonymous nature of reporting in the study, it was not possible to assign (as is done in other methods) a second evaluator to allow concordance analysis. On the other hand, studies based on voluntary reporting more frequently identify active factors, while other studies such as those of an observational nature or based on the use of questionnaires, favor the identification of CFs classified as belonging to other categories.<a class="elsevierStyleCrossRef" href="#bib0310">31</a> In turn, identification of the CFs might not be extrapolatable to other settings outside Intensive Care. A systematic review of CFs related certain factors to the Department or Service in which the study was carried out.<a class="elsevierStyleCrossRef" href="#bib0255">20</a> Lastly, the most frequently reported CFs (almost 20% of the total) were associated to the complexity and seriousness of the patient condition. In view of the study setting, this offers little information, since most critically ill patients present such CFs. Furthermore, such factors were associated to more serious incidents and unavoidable incidents–a correlation that may be due to factors inherent to the reporting persons and to a lack of safety culture among the healthcare professionals. Many professionals consider the most serious incidents to be complications of the disease process itself, and are therefore reported as being patient related and unavoidable–without recognizing them as patient safety problems.While acknowledging the limitations commented above, we consider that the information obtained from the analysis of our results is very useful, since it allows identification and analysis of the CFs with the ultimate aim of better understanding the circumstances that favor or accompany PSRIs in Spanish DICMs. Although there are reference publications in different countries, we consider the availability of studies in our own country to be essential in order to enhance awareness of the importance of a problem that has been little studied in our setting, and which consequently may be underestimated.In sum, the most frequently reported CFs were those related to the patient, followed by factors related to the working conditions and the professional. Most CFs were reported in association to incidents classified as being less serious and avoidable. The CFs related to the professional were associated to less serious and avoidable incidents–fundamentally NMIs–while the CFs related to the patient were associated to more serious incidents that moreover were classified as unavoidable. The majority of the CFs were reported by nursing personnel, followed by physicians.Financial supportThis study was carried out thanks to a collaborative agreement between the Spanish Ministry of Health and the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias, SEMICYUC).Conflict of interestThe authors declare that they have no conflicts of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:3 [ "identificador" => "xres527206" "titulo" => "Abstract" "secciones" => array:7 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Design" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Setting" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Patients" ] 4 => array:2 [ "identificador" => "abst0025" "titulo" => "Main variables" ] 5 => array:2 [ "identificador" => "abst0030" "titulo" => "Results" ] 6 => array:2 [ "identificador" => "abst0035" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec547519" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres527207" "titulo" => "Resumen" "secciones" => array:7 [ 0 => array:2 [ "identificador" => "abst0040" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0045" "titulo" => "Diseño" ] 2 => array:2 [ "identificador" => "abst0050" "titulo" => "Ámbito" ] 3 => array:2 [ "identificador" => "abst0055" "titulo" => "Pacientes" ] 4 => array:2 [ "identificador" => "abst0060" "titulo" => "Variables de interés principales" ] 5 => array:2 [ "identificador" => "abst0065" "titulo" => "Resultados" ] 6 => array:2 [ "identificador" => "abst0070" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec547520" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Material and methods" ] 6 => array:3 [ "identificador" => "sec0015" "titulo" => "Results" "secciones" => array:6 [ 0 => array:2 [ "identificador" => "sec0020" "titulo" => "Reported contributing factors" ] 1 => array:2 [ "identificador" => "sec0025" "titulo" => "Reported contributing factors according to the types of patient safety related incidents" ] 2 => array:2 [ "identificador" => "sec0030" "titulo" => "Reported contributing factors according to the classes of patient safety related incidents" ] 3 => array:2 [ "identificador" => "sec0035" "titulo" => "Groups of contributing factors in relation to the reporting professional" ] 4 => array:2 [ "identificador" => "sec0040" "titulo" => "Groups of contributing factors in relation to the severity of the incident" ] 5 => array:2 [ "identificador" => "sec0045" "titulo" => "Groups of contributing factors in relation to the avoidability of the incident" ] ] ] 7 => array:2 [ "identificador" => "sec0050" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0055" "titulo" => "Financial support" ] 9 => array:2 [ "identificador" => "sec0060" "titulo" => "Conflict of interest" ] 10 => array:2 [ "identificador" => "xack179848" "titulo" => "Acknowledgements" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2014-04-08" "fechaAceptado" => "2014-06-04" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec547519" "palabras" => array:5 [ 0 => "Patient safety" 1 => "Incidents" 2 => "Adverse events" 3 => "Risk management" 4 => "Intensive Care Medicine" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec547520" "palabras" => array:5 [ 0 => "Seguridad del paciente" 1 => "Incidentes" 2 => "Eventos adversos" 3 => "Gestión del riesgo" 4 => "Medicina Intensiva" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "ObjectiveTo explore contributing factors (CFs) associated to related critical patients safety incidents. DesignSYREC study post hoc analysis. SettingA total of 79 Intensive Care Departments were involved. PatientsThe study sample consisted of 1.017 patients; 591 were affected by one or more incidents. Main variablesThe CFs were categorized according to a proposed model by the National Patient Safety Agency from United Kingdom that was modified. Type, class and severity of the incidents were analyzed. ResultsA total 2965 CFs were reported (1729 were associated to near miss and 1236 to adverse events). The CFs group more frequently reported were related patients factors. Individual factors were reported more frequently in near miss and task related CFs in adverse events. CFs were reported in all classes of incidents. The majority of CFs were reported in the incidents classified such as less serious, even though CFs patients factors were associated to serious incidents. Individual factors were considered as avoidable and patients factors as unavoidable. ConclusionsThe CFs group more frequently reported were patient factors and were associated to more severe and unavoidable incidents. By contrast, individual factors were associated to less severe and avoidable incidents. In general, CFs most frequently reported were associated to near miss." "secciones" => array:7 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Design" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Setting" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Patients" ] 4 => array:2 [ "identificador" => "abst0025" "titulo" => "Main variables" ] 5 => array:2 [ "identificador" => "abst0030" "titulo" => "Results" ] 6 => array:2 [ "identificador" => "abst0035" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "ObjetivoAnalizar los factores contribuyentes (FC) que intervienen en la aparición de incidentes relacionados con la seguridad del paciente crítico. DiseñoAnálisis post hoc del estudio SYREC. ÁmbitoUn total de 79 servicios de Medicina Intensiva. PacientesUn total de 1.017 pacientes, de los que se incluyeron 591 en los que se notificó al menos un incidente. Variables de interés principalesFC categorizados según una adaptación del modelo propuesto por la National Patient Safety Agency del Reino Unido. Tipo, clase y gravedad de los incidentes relacionados con la seguridad del paciente. ResultadosSe notificaron 2.965 FC (1.729 se comunicaron en incidentes sin daño y 1.236 en eventos adversos). El grupo de FC más frecuente fue el relacionado con el paciente. Los FC relacionados con el profesional se notificaron más en los incidentes sin daño. En cambio, los relacionados con la tarea se comunicaron más en los eventos adversos. Se declararon FC en todas las clases de incidentes. La mayoría de FC se notificaron en los incidentes menos graves aunque los FC relacionados con el paciente se asociaron a incidentes de mayor gravedad. Los incidentes que se asociaron a los FC relacionados con el profesional se consideraron evitables y los FC relacionados con el paciente, inevitables. ConclusionesLos FC relacionados con el paciente fueron los más frecuentes y se relacionaron con los incidentes más graves y considerados inevitables. Los relacionados con el profesional se notificaron en las categorías menos graves y se consideraron evitables. La identificación de FC fue más frecuente en los incidentes sin daño." "secciones" => array:7 [ 0 => array:2 [ "identificador" => "abst0040" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0045" "titulo" => "Diseño" ] 2 => array:2 [ "identificador" => "abst0050" "titulo" => "Ámbito" ] 3 => array:2 [ "identificador" => "abst0055" "titulo" => "Pacientes" ] 4 => array:2 [ "identificador" => "abst0060" "titulo" => "Variables de interés principales" ] 5 => array:2 [ "identificador" => "abst0065" "titulo" => "Resultados" ] 6 => array:2 [ "identificador" => "abst0070" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Martín Delgado MC, Merino de Cos P, Sirgo Rodríguez G, Álvarez Rodríguez J, Gutiérrez Cía I, Obón Azuara B, et al. Análisis de los factores contribuyentes en incidentes relacionados con la seguridad del paciente en Medicina Intensiva. Med Intensiva. 2015;39:263–271." ] ] "multimedia" => array:5 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1685 "Ancho" => 2374 "Tamanyo" => 256961 ] ] "descripcion" => array:1 [ "en" => "Distribution of contributing factors according to class and type of incidents." ] ] 1 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "Source: Adapted from the classification of medication error of the Ruiz-Jarabo group. Otero-López et al.<a class="elsevierStyleCrossRef" href="#bib0220">13</a>" "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=""><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Incident without damage \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Category A: circumstances or situations that could cause an incident but which are discovered and resolved before they are able to reach the patient \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Category B: the incident reaches the patient but causes no damage. No monitoring or intervention is required \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Category C: the incident reaches the patient and causes no damage, but requires monitoring or intervention to check that no damage has occurred \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Adverse event \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Category D: the incident caused damage that is impossible to determine \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Category E: the incident contributed to or caused temporary patient damage and required intervention \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Category F: the incident contributed to or caused temporary patient damage and required or prolonged hospital admission \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Category G: the incident contributed to or caused permanent patient damage \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Category H: the incident proved life-threatening for the patient and required intervention to ensure survival \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Category I: the incident contributed to or caused the death of the patient \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab849413.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Severity categories of the incidents according to their classification." ] ] 2 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "AE: adverse event; CF: contributing factor; PSRI: patient safety related incident; NMI: near-miss incident; MV: mechanical ventilation." "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"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">CF group \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">CF percentages \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Most frequently reported factors in each CF group (%) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Classes of incidents related to each CF group (%) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Types of incidents related to each CF group (%) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Avoidability of the PSRI \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Individual factors of the professional \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">19.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Cognitive factors (8.9)Stress (5.5)Lack of motivation (2.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Medication (33.6)Diagnostic tests (32.6)Transfusions (28.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NMI (79.4)AE (20.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Avoidable \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Team and social factors \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Undefined roles (0.9)Lack of leadership (0.5)(-) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Diagnostic tests (4.8)Procedures (4.4)Airway and MV (3.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NMI (61.9)AE (38.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">In all the categories \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Communication factors \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Ambiguous verbal instructions (2.3)Poorly directed instructions (0.6)Lack of understanding (1.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Medication (14.8)Diagnostic error (11.5)Diagnostic tests (10.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NMI (80.7)AE (19.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Avoidable \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Task related factors \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Lack of protocols (4.3)Non-adhesion to protocols (2.3)Outdated protocols (1.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Nosocomial infection (20.4)Diagnostic error (15.3)Care (14.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NMI (42.6)AE (57.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Avoidable \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Training and education \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Lack of supervision (4.9)Lack of training (4.5)Lack of knowledge (5.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Procedures (20.5)Diagnostic error (23.1)Vascular accesses (16.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NMI (56.4)AE (43.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Avoidable \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Equipment and resources \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Incorrect functioning (4.7)Inadequate maintenance (1.7)Incorrect location (0.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Equipment (46.3)Procedures (8)Care (5.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NMI (82.9)AE (17.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Unavoidable \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Working conditions \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">19.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Excessive workload (6.9)Time pressure (3.9)New personnel (2.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Transfusions (46.3)Diagnostic error (26.9)Medication (20.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NMI (59.8)AE (40.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Avoidable \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Patient related factors \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">21.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Complexity (10.4)Severity (8.7)Behavioral alteration (1.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Surgery (65.6)Nosocomial infection (48.3)Airway and MV (29.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NMI (30.4)AE (69.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Unavoidable \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab849415.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Characteristics of the contributing factors distributed by groups." ] ] 3 => array:7 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "CF: contributing factor." "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"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Nurse, n (%) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Staff physician, n (%) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Resident, n (%) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Nursing assistant, n (%) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Other, n (%) \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Individual factors of the professional \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">354 (21.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">102 (11.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">66 (25.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">45 (28.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 (29.6) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Team and social \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">23 (1.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14 (1.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 (1.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Communication \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">108 (6.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">20 (2.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12 (4.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 (3.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Task related \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">126 (7.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">83 (9.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">30 (11.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10 (6.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Training and education \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">228 (14) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">162 (18.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">33 (12.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">23 (14.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 (14.8) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Equipment and resources \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">189 (11.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">30 (3.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">24 (9.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">20 (12.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Working conditions \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">327 (20.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">197 (21.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">27 (10.42 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">34 (21.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 (25.9) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Patient related \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">272 (16.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">288 (32.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">62 (23.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">19 (12.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 (29.6) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Total \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.627 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">896 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">259 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">156 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">27 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab849414.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Distribution of the groups of contributing factors according to the reporting professional." ] ] 4 => array:7 [ "identificador" => "tbl0020" "etiqueta" => "Table 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "AE: adverse event; CF: contributing factor; NMI: near-miss incident." "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"><th class="td" title="table-head " align="" valign="top" scope="col"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Undoubtedly avoidable</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Possibly avoidable</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Possibly unavoidable</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Unavoidable</th><th class="td" title="table-head " align="left" valign="top" scope="col">Total \t\t\t\t\t\t\n \t\t\t\t</th></tr><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">n \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">% \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">n \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">% \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">n \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">% \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">n \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">% \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">n \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Professional \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">401 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">69.74 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">154 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">26.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">17 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.96 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.52 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">575 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Team \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">31 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">73.81 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">23.81 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.00 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.38 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">42 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Communication \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">109 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">75.17 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">32 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">22.07 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.38 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.38 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">145 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Task \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">100 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">40.16 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">124 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">49.80 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">17 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6.83 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3.21 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">249 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Training and education \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">259 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">57.56 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">181 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">40.22 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.33 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.89 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">450 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Equipment and resources \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">126 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">47.91 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">79 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">30.04 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">41 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15.59 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">17 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6.46 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">263 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Working conditions \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">354 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">59.80 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">218 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">36.82 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">19 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3.21 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.17 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">592 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Patient \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">106 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">16.33 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">251 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">38.67 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">243 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">37.44 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">49 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7.55 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">649 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab849416.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Distribution of reported contributing factors according to avoidability of the incident." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:31 [ 0 => array:3 [ "identificador" => "bib0160" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "How safe is my intensive care unit? 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Sant Joan de Deu (Espluges); Alonso Ovies A, Balugo Huertas S, H. de Fuenlabrada (Fuenlabrada); Audicana Uriarte J, Sánchez Villamar AM, H. de Galdakao (Galdakao); Álvarez Villuendas A, Garfingou Llenas D, H. Dr. Josep Trueta (Gerona); Roca Guiseris J, García R, H. Virgen de las Nieves (Granada); Fernández del Campo R, Buendía F, H. de Hellín (Hellín); Bartual Lobato E, García Verdejo JA, H. Can Misses (Ibiza); Verduras Ruiz MA, Rodrigo Frontelo R, H. Severo Ochoa (Leganés); Pavía Pesquera MC, Pardos Peirós E, H. San Pedro (Logroño); Blanco Pérez J, Murado Bouso AM, H. Xeral-Calde Lugo (Lugo); Gómez Tello V, del Pozo Y, Clínica Moncloa (Madrid); Reyes García A, Toledano Peña J, H.U. de la Princesa (Madrid); Ramos Polo J, Suay Ojalvo C, H. Clínico San Carlos (Madrid); Menéndez de Suso JJ, Segovia Gaitán M, H. San Rafael (Madrid); Sáenz Casco L, Andrés Sarriá M, H. Central de la Defensa Gómez Ulla (Madrid); Jiménez Lendínez M, Romero C, H.U. La Paz (Madrid); Arias Verdú MD, García Santana JL, H. Parque San Antonio (Málaga); Arboleda Sánchez JA, Velasco Bueno JM, H. Costa del Sol (Marbella); Solsona Perlasia M, Vilalta Llibre M, Consorci Sanitari del Maresme (CSdM) (Mataró); García Fernández AM, Morales Adeva L, H. de Mérida (Mérida); Galdos Anuncibay P, Arias Castro I, H.G. de Móstoles (Móstoles); Gómez Ramos MJ, Cevidanes M, H.G.U. Reina Sofía (Murcia); Martínez Fresneda M, Banacloche Cano C, H. Virgen de la Arrixaca (Murcia); Carrillo Alcaraz A, Peñalver F, H. Morales Meseguer (Murcia); Iglesias Fraile L, Álvarez Méndez B, H.G. de Asturias (Oviedo); Rialp Cervera G, Bestard Socías C, H. Son Llàtzer (Palma de Mallorca); Rodríguez Albarrán F, Ballester Belcos R, Clínica San Miguel (Pamplona); Ramos Castro J, Herranz Ayesa MV, H. Virgen del Camino (Pamplona); Martínez Urionabarrenetxea K, Elizondo Soto A, H. de Navarra (Pamplona); Gil Cebrián J, Delgado Poullet N, H.U. 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Miguel Servet-Cirugía Cardiaca (Zaragoza); Williams L, Patiño Y, Centro de Especialidades Anzoátegui, Lechería (Venezuela); Margarit Ribas A, Flamarique Zaratiegui MT, H. Nostra Senyora de Meritxell, Escaldes-Engordany (Andorra); Ortega RA, Sánchez Reinoso J, San Juan Bautista, Catamarca (Argentina); Diosdado Iraola Ferrer M, Mora Pérez Y, H.U. Dr. Gustavo Aldereguía Lima, Cienfuegos (Cuba); Carrazana Osorio V, Prieto Fuentemayor JR, H. Clínico-Quirúrgico Lucía Íñiguez Landín, Holguín (Cuba); Díaz Águila H, Companioni Sola Y, H. Mártires de 9 de Abril, Sagua la Grande (Cuba); Morales Valderas A, Solís Sotero M, H.U. Arnaldo Milian Castro, Santa Clara (Cuba)." "vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/21735727/0000003900000005/v1_201506260204/S217357271500034X/v1_201506260204/en/main.assets" "Apartado" => null "PDF" => "https://static.elsevier.es/multimedia/21735727/0000003900000005/v1_201506260204/S217357271500034X/v1_201506260204/en/main.pdf?idApp=WMIE&text.app=https://medintensiva.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S217357271500034X?idApp=WMIE"]

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Analysis of contributing factors associated to related patients safety incidents in Intensive Care Medicine

Análisis de los factores contribuyentes en incidentes relacionados con la seguridad del paciente en Medicina Intensiva

M.C. Martín Delgadoa,

Corresponding author

mmartin@torrejonsalud.com

Corresponding author.

, P. Merino de Cosb, G. Sirgo Rodríguezc, J. Álvarez Rodríguezd, I. Gutiérrez Cíae, B. Obón Azuaraf, Á. Alonso Oviesd, Grupo SYREC

a Servicio de Medicina Intensiva, Hospital Universitario de Torrejón, Torrejón de Ardoz, Madrid, Spain

b Servicio de Medicina Intensiva, Hospital Can Misses, Ibiza, Spain

c Unidad de Cuidados Intensivos, Hospital Universitario Joan XXIII, Instituto de Investigación Sanitaria Pere Virgili, Universidad Rovira i Virgili, Tarragona, Spain

d Servicio de Medicina Intensiva, Hospital Universitario de Fuenlabrada, Fuenlabrada, Madrid, Spain

e Servicio de Medicina Intensiva, Hospital Clínico Universitario, Zaragoza, Spain

f Servicio de Medicina Preventiva y Salud Pública, Hospital Clínico Universitario, Zaragoza, Spain

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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The critical patient care environment is extremely complex&#46; In Departments of Intensive Care Medicine &#40;DICMs&#41;&#44; factors such as the seriousness of the patient condition&#44; the communication barriers&#44; the invasive therapeutic and diagnostic procedures used&#44;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">1</span></a> and the volume of information managed all contribute to the appearance of incidents related to patient safety&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Although not all healthcare related incidents that occur in the DICM actually affect the patients&#44; some of them can cause temporary damage requiring additional observation and care&#44; prolonging hospital stay and&#8211;in some cases&#8211;causing permanent damage or even death&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Two aspects must be underscored in this regard&#46; Firstly&#44; most incidents detected in the DICM are avoidable&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">4</span></a> Secondly&#44; although errors can occur in all areas of the hospital&#44; patients admitted to the DICM are more vulnerable&#44; and the consequences are more serious&#46;<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">5&#44;6</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">In the patient safety context&#44; it is admitted that most incidents related to medical care are a consequence of active error on the part of the professionals&#44; favored by factors latent within the system&#46; The analysis of these factors&#44; applied to clinical safety&#44; has been carried out based on the results of safety analyses in other fields such as aviation&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">7</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">A modern approach by those institutions that aim to effectively address patient safety with the purpose of reducing the number of incidents related to medical care inevitably includes knowledge of the causes underlying such incidents and their contributing factors &#40;CFs&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">8</span></a> Furthermore&#44; in-depth knowledge of these factors makes it possible to distinguish between those that influence an isolated incident and those which are common to incidents within a certain institution or Department&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">9</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">The systematic classification of CFs and their analysis should allow the development of strategies for improving the defenses and failures of the system&#46; In Spain there is no exhaustive information on incidents related to medical care in the critical care setting&#44; and the lack of data is even more manifest when considering the factors related to the appearance of such incidents&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">10</span></a> For this reason&#44; a collaborative agreement was established between the Spanish Ministry of Health and the Spanish Society of Intensive and Critical Care Medicine and Coronary Units &#40;<span class="elsevierStyleItalic">Sociedad Espa&#241;ola de Medicina Intensiva&#44; Cr&#237;tica y Unidades Coronarias</span>&#44; SEMICYUC&#41; to conduct the multicenter Safety and Risk in the Critical Patient &#40;<span class="elsevierStyleItalic">Seguridad y Riesgo en el Enfermo Cr&#237;tico</span>&#44; SYREC&#41; study&#8211;the main objective of which was to estimate the incidence of adverse events &#40;AEs&#41; and near-miss incidents &#40;NMIs&#41; in the Intensive Care setting&#44; classify them&#44; and assess their impact and avoidability&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">11</span></a> The results of this study have recently been published&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">4</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The present study analyzes the factors that contribute to the appearance of NMIs and AEs in the critical patient&#44; and explores their relation to the class&#44; severity and avoidability of incidents related to medical care&#44; based on the results of the SYREC study&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Material and methods</span><p id="par0040" class="elsevierStylePara elsevierViewall">Design&#58; A <span class="elsevierStyleItalic">post hoc</span> analysis was made of the SYREC study &#40;a multicenter&#44; prospective cohort observational study with a follow-up duration of 24<span class="elsevierStyleHsp" style=""></span>h&#44; 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team and social factors&#44; communication factors&#44; task related factors&#44; equipment and resource related factors&#44; working conditions&#44; patient factors&#44; and training and educational factors&#46; Each group of CFs in turn could comprise one or more subfactors&#46; For each reported patient safety related incident &#40;PSRI&#41;&#44; the notifier could consider one or more groups of CFs and&#44; within each group&#44; one or more related subfactors&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">b&#41;</span><p id="par0060" class="elsevierStylePara elsevierViewall">Secondary &#40;classes of incidents related to medical care&#41;&#58; we included NMIs and AEs occurring&#44; detected and reported during the observation period in the Unit&#44; as well as those occurring outside the Unit but which were the reason for admission to the latter&#46; Near-miss incidents were defined as incidents causing no patient damage&#44; either because they fail to actually reach the patient&#44; or because they produce no consequences even if they do reach the patient&#46; Adverse events in turn were defined as unforeseen and unexpected incidents reported by the professionals and which cause damage&#44; disability or prolongation of stay&#44; or death as a consequence of medical care and which are unrelated to the evolution or possible complications of the patient background disease&#46;</p></li></ul></p><p id="par0065" class="elsevierStylePara elsevierViewall">Class of incident &#40;classification adopted by the authors based on the literature&#41;&#58; The incidents were divided into in 11 classes&#58; &#40;1&#41; medication&#59; &#40;2&#41; blood and blood product transfusions&#59; &#40;3&#41; airway and mechanical ventilation&#59; &#40;4&#41; vascular accesses&#44; catheters&#44; tubes&#44; drains and sensors&#59; &#40;5&#41; medical equipment and system failure&#59; &#40;6&#41; diagnostic error&#59; &#40;7&#41; diagnostic tests&#59; &#40;8&#41; nursing care&#59; &#40;9&#41; procedures&#59; &#40;10&#41; nosocomial infection&#59; and &#40;11&#41; surgery related incidents&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Severity of the incident&#58; This was analyzed based on an adaptation of the classification of medication errors of the Ruiz-Jarabo group&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">13</span></a> The changes affected categories A and B&#44; which were merged&#46; A new category &#40;category D&#41; was added&#44; due to the difficulty in many cases of assessing the consequences of the incident &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">Avoidability of the incident&#58; The NMIs and AEs were classified as follows according to the criterion of the observer&#58; undoubtedly avoidable&#44; possibly avoidable&#44; possibly unavoidable or unavoidable&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Procedure&#58; All the DICMs in Spain &#40;a total of 220&#41; were invited to participate through the SEMICYUC website&#44; e-mail or conventional mail&#46; A total of 79 DICMs finally agreed to participate&#46; After confirming acceptance&#44; each Unit assigned two coordinators &#40;a physician and a nurse&#41;&#44; who in turn received a document describing the study design and providing instructions to standardize the inclusion criteria and data collection&#46; Supportive and training material was also made available to all the professionals in the Units&#44; before the start of the study&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">A questionnaire distributed in paper format was used for data collection&#46; On the day of the study&#44; all the physicians&#44; nurses and assistant personnel completed the corresponding questionnaires on a voluntary and anonymous basis&#46; The coordinators in each center checked correct completion of the questionnaires&#44; entered the data in an electronic format and forwarded them by e-mail to the principal investigators of the study&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Data collection quality control&#58; All the reported incidents were individually reviewed by the principal investigators of the study&#46; A consensus meeting was subsequently held to examine the discrepancies and decide whether to include or exclude them&#44; and to reclassify those incidents which were considered to be incorrectly classified&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Statistical analysis&#58; A descriptive analysis was made of all the variables included in the study&#46; Qualitative variables were reported as frequency distributions&#44; while quantitative variables were presented using the mean and standard deviation &#40;SD&#41; as dispersion measures&#44; or the median and interquartile range &#40;IQR&#41; in the event of an asymmetric distribution&#46; In the bivariate analysis&#44; the possible association between quantitative variables was evaluated using the chi-squared test&#46; The comparison of means for two independent samples in turn was carried out using the Student <span class="elsevierStyleItalic">t</span>-test for independent samples&#44; with analysis of variance &#40;ANOVA&#41; in the case of more than two means&#8211;in both cases considering a symmetric &#40;normal&#41; sample distribution as established by the homogeneity of variance analysis&#46; In the case of an asymmetric distribution&#44; we used the median test for the contrasting of hypotheses&#46; The data were entered in a MS Access database&#44; followed by statistical processing with the SPSS version 19&#46;0 statistical package&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Confidentiality and ethical considerations&#58; Since this was an observational study involving no interventions of any kind&#44; the obtainment of informed consent was not considered necessary&#46; The study was approved by the Clinical Research Ethics Committee &#40;CREC&#41; of Aragon&#46; Each DICM agreed to obtain the required permissions at local level&#46; In accordance with Act 15&#47;1999 referring to the protection of personal data&#44;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">14</span></a> and with Act 41&#47;2002&#44; of 14 November&#44; regulating patient autonomy and rights and obligations in relation to clinical documentation and information&#44;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">15</span></a> the anonymity of the patients and of the personnel involved in the incidents was ensured in the collected and submitted data&#46; The results of this study were not directly binding for either the professionals or the patients&#44; and the decision was made to publish both the positive and the negative findings&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Results</span><p id="par0105" class="elsevierStylePara elsevierViewall">A total of 79 DICMs belonging to 76 hospitals participated in the study&#44; with the inclusion of 1017 patients&#46; At least one incident was reported in 591 of these patients &#40;58&#37;&#41;&#46; During the study period a total of 1424 patient safety related incidents &#40;PSRIs&#41; were reported&#58; 943 NMIs &#40;66&#37;&#41; and 481 AEs &#40;44&#37;&#41;&#46; One or more contributing factors &#40;CFs&#41; were reported in 1247 PSRIs &#40;87&#46;57&#37;&#41;&#46;</p><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Reported contributing factors</span><p id="par0110" class="elsevierStylePara elsevierViewall">A total of 2965 CFs were documented&#44; of which 1729 &#40;58&#46;31&#37;&#41; were reported in relation to 943 NMIs and 1236 &#40;41&#46;69&#37;&#41; in relation to 481 AEs&#8211;this representing a median of one CF per NMI &#40;IQR 1&#8211;2&#41; and of two CFs per AE &#40;IQR 1&#8211;3&#41;&#40;p&#160;&#60;&#160;0&#46;001&#41;&#46; No CFs was reported in 12&#46;7&#37; of the NMIs and in 11&#46;9&#37; of the AEs&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">The most frequently reported CFs corresponded to patient related factors &#40;21&#46;9&#37;&#41;&#44; followed by the working conditions &#40;19&#46;9&#37;&#41;&#44; and individual factors of the professional &#40;19&#46;4&#37;&#41;&#46; <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> describes the frequencies with which the different groups of CFs were reported&#46; The table also describes the most common subfactors cited in each group of CFs and their main characteristics&#46; It should be noted that complexity and severity were the factors most often cited in the group of patient related factors&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Reported contributing factors according to the types of patient safety related incidents</span><p id="par0120" class="elsevierStylePara elsevierViewall">The groups of CFs corresponding to equipment and resources&#44; communication and individual professional factors were more frequently reported in NMIs &#40;82&#46;9&#37;&#44; 80&#46;7&#37; and 79&#46;4&#37;&#44; respectively&#41;&#46; In contrast&#44; the groups of CFs related to patient&#44; task and training and education were more frequently reported in AEs &#40;69&#46;6&#37;&#44; 57&#46;4&#37; and 43&#46;6&#37;&#44; respectively&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Reported contributing factors according to the classes of patient safety related incidents</span><p id="par0125" class="elsevierStylePara elsevierViewall">Incidents corresponding to all 11 of the considered classes were reported&#46; The class of incidents with the greatest percentage of reported CFs corresponded to diagnostic error &#40;93&#46;7&#37;&#59; 16 incidents related to medical care&#44; and only one incident with no CF&#41; and surgery &#40;93&#46;6&#37;&#59; 47 incidents related to medical care&#44; only 3 incidents with no CF&#41;&#46; In contrast&#44; the class of incidents with the lowest percentage of reported CFs corresponded to transfusion &#40;80&#37;&#41;&#46; However&#44; it must be noted that only 5 incidents were documented in this class&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> describes the classes of incidents related to each group of CFs&#46; Within the group of CFs related to the patient&#44; the most common incidents corresponded to surgery&#46; In contrast&#44; the working conditions and individual factors of the professional were more often associated to transfusion and medication incidents&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">On the other hand&#44; <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a> summarizes the distribution of the reported CFs according to the class and type of incident involved&#46; Of note is the fact that all reported CFs referred to transfusion corresponded to NMIs&#46; In contrast&#44; 97&#46;9&#37; of the CFs reported in the context of surgical incidents corresponded to AEs&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Groups of contributing factors in relation to the reporting professional</span><p id="par0140" class="elsevierStylePara elsevierViewall">Of the 2965 documented CFs&#44; 1627 were reported by nursing personnel&#44; 896 by staff physicians&#44; 259 by residents in training&#44; 156 by nursing assistants&#44; and 27 by other professionals&#46; In general&#44; physicians were the most frequent reporters of patient related factors &#40;32&#46;1&#37;&#41; and&#44; in contrast&#44; the least frequent reporters of individual factors of the professional &#40;11&#46;4&#37;&#41; and factors related to equipment and resources &#40;3&#46;3&#37;&#41;&#46; On the other hand&#44; residents in training were the professionals who reported the fewest incidents involving CFs related to working conditions &#40;10&#46;4&#37;&#41;&#46; <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a> shows the number of CFs reported according to groups of factors and the reporting persons&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Groups of contributing factors in relation to the severity of the incident</span><p id="par0145" class="elsevierStylePara elsevierViewall">Most of the CFs &#40;2011&#59; 67&#46;8&#37;&#41; corresponded to incidents classified as being less serious &#40;categories A and D&#41;&#44; while 954 &#40;32&#59; 2&#37;&#41; corresponded to more serious incidents &#40;categories E-I&#41;&#46; The group of CFs related to greatest severity of the PSRIs corresponded to patient related factors&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Groups of contributing factors in relation to the avoidability of the incident</span><p id="par0150" class="elsevierStylePara elsevierViewall">A total of 2535 CFs corresponded to 1136 incidents related to patient safety classified as &#8220;undoubtedly avoidable&#8221; or &#8220;possibly avoidable&#8221;&#44; while 430 CFs corresponded to 288 incidents classified as &#8220;possibly unavoidable&#8221; or &#8220;unavoidable&#8221;&#46; <a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a> shows the distribution of reported CFs by groups and according to the avoidability of the incident&#46; The individual factors of the professional and factors related to the working conditions were associated to avoidable PSRIs&#46; In contrast&#44; the CFs related to the patient and equipment and resources were associated to unavoidable PSRIs&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Discussion</span><p id="par0155" class="elsevierStylePara elsevierViewall">The contributing factors &#40;CFs&#41; that intervene in the appearance of patient safety related incidents &#40;PSRIs&#41; have been little investigated in the Intensive Care setting&#46; To date&#44; and from outside the context of critical care&#44; the different publications have attempted to investigate CFs through retrospective studies<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">16&#8211;19</span></a> or based on reporting systems&#46;<a class="elsevierStyleCrossRefs" href="#bib0255"><span class="elsevierStyleSup">20&#8211;23</span></a> More recently&#44; studies from the perspective of medicine based on evidence have attempted to structure CFs into groups that can help us understand the appearance of PSRIs&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">24</span></a> In this regard&#44; Lawton et al&#46; identified active errors &#40;failure to adhere to norms and protocols&#41;&#44; together with factors related to the individual &#40;knowledge and experience&#41;&#44; and communication deficiencies&#44; as the groups of CFs most frequently implicated in the appearance of PSRIs&#46; The same authors also underscored a weakness that can be extended to any study that obtains information through reporting&#58; the reporting professional is probably not an expert in safety matters&#44; and is only able to point to the causes closest to the incident&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">In our study&#44; based on voluntary reporting encouraged by the coordinators&#44; the most frequently reported CFs were those related to the patient&#46; This is not surprising&#44; since critically ill patients are particularly vulnerable to PSRIs because of the inherent seriousness of their condition&#46; The second most frequently reported CFs corresponded to the working conditions&#46; In this regard&#44; Sanghera et al&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">25</span></a> pointed to the working conditions as the main CFs associated to medication error in critical patients&#44; followed by communication related factors&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">The data contained in the literature are heterogeneous&#46; As an example&#44; studies based on systems for reporting incidents in DICMs have found the most frequently reported CFs to be human factors&#44; followed by systemic factors such as the working conditions&#44; equipment and communication&#44; among others&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">26</span></a> On the other hand&#44; and likewise based on a multicenter reporting system in different North American DICMs&#44; Holzmueller et al&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">27</span></a> found the CFs most frequently associated to PSRIs to be related to training and education&#44; followed by communication related factors&#46; Probably one of the elements that explain the lack of concordance in relation to the reported CFs is the methodology used in detecting the incidents&#44; which can give rise to different interpretations regarding the CFs&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">26</span></a></p><p id="par0170" class="elsevierStylePara elsevierViewall">We consider a number of the findings of our study to be of interest&#46; On one hand&#44; the number of CFs reported in AEs was greater than in NMIs&#46; Although the causal mechanism underlying incidents with and without damage or injury is similar&#44; professionals identify more CFs when the patient experiences damage&#46; This may be because the search to identify what has happened is more intense when damage in the form of an AE has effectively occurred&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">9</span></a> On the other hand&#44; it should be mentioned that the reported CFs differ when separately considering NMIs and AEs&#46; Among the former&#44; the most frequently reported CFs corresponded to individual factors of the professional&#44; followed by communication factors&#46; In contrast&#44; on considering AEs&#44; the most frequently reported CFs were seen to be related to the task and to the patient&#46; It should be noted that the group of CFs related to the task includes aspects as important as the lack of specific protocols or failure to adhere to the existing protocols&#46; The former problem is relatively easy to solve by developing the necessary protocols&#44; while the latter &#40;failure to adhere to the existing protocols or even to internationally accepted treatment guides&#41; is the subject of continuous analysis&#46;<a class="elsevierStyleCrossRefs" href="#bib0295"><span class="elsevierStyleSup">28&#44;29</span></a></p><p id="par0175" class="elsevierStylePara elsevierViewall">Another aspect that should be commented is the correlation of the CFs to the class of PSRI&#46; In this regard&#44; patient related factors&#8211;which generally speaking were the most frequently cited CFs&#8211;were associated to surgery related incidents&#46; This may be because surgical procedures are typically performed in seriously ill patients&#46; In turn&#44; professional factors&#44; which were the most commonly reported CFs in NMIs&#44; were associated to medication error&#46; Lastly&#44; task related factors&#44; which were the most commonly reported CFs in AEs&#44; were associated to nosocomial infection&#46; This circumstance again points to error of omission &#40;failure to adhere to the clinical practice guides&#41; as possibly being the cause of AEs as sensitive as infection associated to medical care&#46;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">30</span></a></p><p id="par0180" class="elsevierStylePara elsevierViewall">In relation to avoidability&#44; most of the incidents were classified as avoidable&#44; in coincidence with the observations of other authors&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">19</span></a> The groups of CFs related to avoidable PSRIs were individual factors of the professional&#44; followed by equipment related factors&#46; In contrast&#44; the unavoidable incidents were fundamentally associated to patient related factors&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">This study has some limitations&#46; On one hand&#44; in relation to the methodology used&#44; the incidents were recorded by professionals working in the DICMs&#46; Although these professionals had received basic information on patient safety&#44; they cannot be regarded as experts in this field&#8211;a fact that limits the detection of CFs&#46; At the same time&#44; although reporting by the professionals can allow the identification of CFs that are not easy to identify with other methods &#40;e&#46;g&#46;&#44; case history reviews&#41;&#44; it may limit assessment of the CFs by not offering a true root cause analysis&#46; Given the voluntary and anonymous nature of reporting in the study&#44; it was not possible to assign &#40;as is done in other methods&#41; a second evaluator to allow concordance analysis&#46; On the other hand&#44; studies based on voluntary reporting more frequently identify active factors&#44; while other studies such as those of an observational nature or based on the use of questionnaires&#44; favor the identification of CFs classified as belonging to other categories&#46;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">31</span></a> In turn&#44; identification of the CFs might not be extrapolatable to other settings outside Intensive Care&#46; A systematic review of CFs related certain factors to the Department or Service in which the study was carried out&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">20</span></a> Lastly&#44; the most frequently reported CFs &#40;almost 20&#37; of the total&#41; were associated to the complexity and seriousness of the patient condition&#46; In view of the study setting&#44; this offers little information&#44; since most critically ill patients present such CFs&#46; Furthermore&#44; such factors were associated to more serious incidents and unavoidable incidents&#8211;a correlation that may be due to factors inherent to the reporting persons and to a lack of safety culture among the healthcare professionals&#46; Many professionals consider the most serious incidents to be complications of the disease process itself&#44; and are therefore reported as being patient related and unavoidable&#8211;without recognizing them as patient safety problems&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">While acknowledging the limitations commented above&#44; we consider that the information obtained from the analysis of our results is very useful&#44; since it allows identification and analysis of the CFs with the ultimate aim of better understanding the circumstances that favor or accompany PSRIs in Spanish DICMs&#46; Although there are reference publications in different countries&#44; we consider the availability of studies in our own country to be essential in order to enhance awareness of the importance of a problem that has been little studied in our setting&#44; and which consequently may be underestimated&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">In sum&#44; the most frequently reported CFs were those related to the patient&#44; followed by factors related to the working conditions and the professional&#46; Most CFs were reported in association to incidents classified as being less serious and avoidable&#46; The CFs related to the professional were associated to less serious and avoidable incidents&#8211;fundamentally NMIs&#8211;while the CFs related to the patient were associated to more serious incidents that moreover were classified as unavoidable&#46; The majority of the CFs were reported by nursing personnel&#44; followed by physicians&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Financial support</span><p id="par0200" class="elsevierStylePara elsevierViewall">This study was carried out thanks to a collaborative agreement between the <span class="elsevierStyleGrantSponsor" id="gs1">Spanish Ministry of Health</span> and the <span class="elsevierStyleGrantSponsor" id="gs2">Spanish Society of Intensive and Critical Care Medicine and Coronary Units</span> &#40;<span class="elsevierStyleItalic">Sociedad Espa&#241;ola de Medicina Intensiva&#44; Cr&#237;tica y Unidades Coronarias</span>&#44; SEMICYUC&#41;&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Conflict of interest</span><p id="par0205" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To explore contributing factors &#40;CFs&#41; associated to related critical patients safety incidents&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Design</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">SYREC study post hoc analysis&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Setting</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A total of 79 Intensive Care Departments were involved&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Patients</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The study sample consisted of 1&#46;017 patients&#59; 591 were affected by one or more incidents&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Main variables</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">The CFs were categorized according to a proposed model by the National Patient Safety Agency from United Kingdom that was modified&#46; Type&#44; class and severity of the incidents were analyzed&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Results</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">A total 2965 CFs were reported &#40;1729 were associated to near miss and 1236 to adverse events&#41;&#46; The CFs group more frequently reported were related patients factors&#46; Individual factors were reported more frequently in near miss and task related CFs in adverse events&#46; CFs were reported in all classes of incidents&#46; The majority of CFs were reported in the incidents classified such as less serious&#44; even though CFs patients factors were associated to serious incidents&#46; Individual factors were considered as avoidable and patients factors as unavoidable&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusions</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">The CFs group more frequently reported were patient factors and were associated to more severe and unavoidable incidents&#46; By contrast&#44; individual factors were associated to less severe and avoidable incidents&#46; In general&#44; CFs most frequently reported were associated to near miss&#46;</p></span>"
        "secciones" => array:7 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Objective"
          ]
          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Design"
          ]
          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Setting"
          ]
          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Patients"
          ]
          4 => array:2 [
            "identificador" => "abst0025"
            "titulo" => "Main variables"
          ]
          5 => array:2 [
            "identificador" => "abst0030"
            "titulo" => "Results"
          ]
          6 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Conclusions"
          ]
        ]
      ]
      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Objetivo</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Analizar los factores contribuyentes &#40;FC&#41; que intervienen en la aparici&#243;n de incidentes relacionados con la seguridad del paciente cr&#237;tico&#46;</p></span> <span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Dise&#241;o</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">An&#225;lisis <span class="elsevierStyleItalic">post hoc</span> del estudio SYREC&#46;</p></span> <span id="abst0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">&#193;mbito</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Un total de 79 servicios de Medicina Intensiva&#46;</p></span> <span id="abst0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Pacientes</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Un total de 1&#46;017 pacientes&#44; de los que se incluyeron 591 en los que se notific&#243; al menos un incidente&#46;</p></span> <span id="abst0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Variables de inter&#233;s principales</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">FC categorizados seg&#250;n una adaptaci&#243;n del modelo propuesto por la National Patient Safety Agency del Reino Unido&#46; Tipo&#44; clase y gravedad de los incidentes relacionados con la seguridad del paciente&#46;</p></span> <span id="abst0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Resultados</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Se notificaron 2&#46;965 FC &#40;1&#46;729 se comunicaron en incidentes sin da&#241;o y 1&#46;236 en eventos adversos&#41;&#46; El grupo de FC m&#225;s frecuente fue el relacionado con el paciente&#46; Los FC relacionados con el profesional se notificaron m&#225;s en los incidentes sin da&#241;o&#46; En cambio&#44; los relacionados con la tarea se comunicaron m&#225;s en los eventos adversos&#46; Se declararon FC en todas las clases de incidentes&#46; La mayor&#237;a de FC se notificaron en los incidentes menos graves aunque los FC relacionados con el paciente se asociaron a incidentes de mayor gravedad&#46; Los incidentes que se asociaron a los FC relacionados con el profesional se consideraron evitables y los FC relacionados con el paciente&#44; inevitables&#46;</p></span> <span id="abst0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Conclusiones</span><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Los FC relacionados con el paciente fueron los m&#225;s frecuentes y se relacionaron con los incidentes m&#225;s graves y considerados inevitables&#46; Los relacionados con el profesional se notificaron en las categor&#237;as menos graves y se consideraron evitables&#46; La identificaci&#243;n de FC fue m&#225;s frecuente en los incidentes sin da&#241;o&#46;</p></span>"
        "secciones" => array:7 [
          0 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Objetivo"
          ]
          1 => array:2 [
            "identificador" => "abst0045"
            "titulo" => "Dise&#241;o"
          ]
          2 => array:2 [
            "identificador" => "abst0050"
            "titulo" => "&#193;mbito"
          ]
          3 => array:2 [
            "identificador" => "abst0055"
            "titulo" => "Pacientes"
          ]
          4 => array:2 [
            "identificador" => "abst0060"
            "titulo" => "Variables de inter&#233;s principales"
          ]
          5 => array:2 [
            "identificador" => "abst0065"
            "titulo" => "Resultados"
          ]
          6 => array:2 [
            "identificador" => "abst0070"
            "titulo" => "Conclusiones"
          ]
        ]
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Mart&#237;n Delgado MC&#44; Merino de Cos P&#44; Sirgo Rodr&#237;guez G&#44; &#193;lvarez Rodr&#237;guez J&#44; Guti&#233;rrez C&#237;a I&#44; Ob&#243;n Azuara B&#44; et al&#46; An&#225;lisis de los factores contribuyentes en incidentes relacionados con la seguridad del paciente en Medicina Intensiva&#46; Med Intensiva&#46; 2015&#59;39&#58;263&#8211;271&#46;</p>"
      ]
    ]
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        "descripcion" => array:1 [
          "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Distribution of contributing factors according to class and type of incidents&#46;</p>"
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        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
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          "leyenda" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Source</span>&#58; Adapted from the classification of medication error of the Ruiz-Jarabo group&#46; Otero-L&#243;pez et al&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">13</span></a></p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Incident without damage</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Category A&#58; circumstances or situations that could cause an incident but which are discovered and resolved before they are able to reach the patient&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Category B&#58; the incident reaches the patient but causes no damage&#46; No monitoring or intervention is required&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Category C&#58; the incident reaches the patient and causes no damage&#44; but requires monitoring or intervention to check that no damage has occurred&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Adverse event</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Category D&#58; the incident caused damage that is impossible to determine&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Category E&#58; the incident contributed to or caused temporary patient damage and required intervention&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Category F&#58; the incident contributed to or caused temporary patient damage and required or prolonged hospital admission&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Category G&#58; the incident contributed to or caused permanent patient damage&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Category H&#58; the incident proved life-threatening for the patient and required intervention to ensure survival&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Category I&#58; the incident contributed to or caused the death of the patient&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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        "descripcion" => array:1 [
          "en" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Severity categories of the incidents according to their classification&#46;</p>"
        ]
      ]
      2 => array:7 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">AE&#58; adverse event&#59; CF&#58; contributing factor&#59; PSRI&#58; patient safety related incident&#59; NMI&#58; near-miss incident&#59; MV&#58; mechanical ventilation&#46;</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"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">CF group&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">CF percentages&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Most frequently reported factors in each CF group &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Classes of incidents related to each CF group &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Types of incidents related to each CF group &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Avoidability of the PSRI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Individual factors of the professional&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">19&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Cognitive factors &#40;8&#46;9&#41;Stress &#40;5&#46;5&#41;Lack of motivation &#40;2&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Medication &#40;33&#46;6&#41;Diagnostic tests &#40;32&#46;6&#41;Transfusions &#40;28&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NMI &#40;79&#46;4&#41;AE &#40;20&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Avoidable&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Team and social factors&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Undefined roles &#40;0&#46;9&#41;Lack of leadership &#40;0&#46;5&#41;&#40;-&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Diagnostic tests &#40;4&#46;8&#41;Procedures &#40;4&#46;4&#41;Airway and MV &#40;3&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NMI &#40;61&#46;9&#41;AE &#40;38&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">In all the categories&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Communication factors&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Ambiguous verbal instructions &#40;2&#46;3&#41;Poorly directed instructions &#40;0&#46;6&#41;Lack of understanding &#40;1&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Medication &#40;14&#46;8&#41;Diagnostic error &#40;11&#46;5&#41;Diagnostic tests &#40;10&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NMI &#40;80&#46;7&#41;AE &#40;19&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Avoidable&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Task related factors&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Lack of protocols &#40;4&#46;3&#41;Non-adhesion to protocols &#40;2&#46;3&#41;Outdated protocols &#40;1&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Nosocomial infection &#40;20&#46;4&#41;Diagnostic error &#40;15&#46;3&#41;Care &#40;14&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NMI &#40;42&#46;6&#41;AE &#40;57&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Avoidable&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Training and education&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Lack of supervision &#40;4&#46;9&#41;Lack of training &#40;4&#46;5&#41;Lack of knowledge &#40;5&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Procedures &#40;20&#46;5&#41;Diagnostic error &#40;23&#46;1&#41;Vascular accesses &#40;16&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NMI &#40;56&#46;4&#41;AE &#40;43&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Avoidable&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Equipment and resources&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Incorrect functioning &#40;4&#46;7&#41;Inadequate maintenance &#40;1&#46;7&#41;Incorrect location &#40;0&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Equipment &#40;46&#46;3&#41;Procedures &#40;8&#41;Care &#40;5&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NMI &#40;82&#46;9&#41;AE &#40;17&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Unavoidable&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Working conditions&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">19&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Excessive workload &#40;6&#46;9&#41;Time pressure &#40;3&#46;9&#41;New personnel &#40;2&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Transfusions &#40;46&#46;3&#41;Diagnostic error &#40;26&#46;9&#41;Medication &#40;20&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NMI &#40;59&#46;8&#41;AE &#40;40&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Avoidable&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Patient related factors&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">21&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Complexity &#40;10&#46;4&#41;Severity &#40;8&#46;7&#41;Behavioral alteration &#40;1&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Surgery &#40;65&#46;6&#41;Nosocomial infection &#40;48&#46;3&#41;Airway and MV &#40;29&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NMI &#40;30&#46;4&#41;AE &#40;69&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Unavoidable&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab849415.png"
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        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">Characteristics of the contributing factors distributed by groups&#46;</p>"
        ]
      ]
      3 => array:7 [
        "identificador" => "tbl0015"
        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0105" class="elsevierStyleSimplePara elsevierViewall">CF&#58; contributing factor&#46;</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"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Nurse&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Staff physician&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Resident&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Nursing assistant&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Other&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Individual factors of the professional&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">354 &#40;21&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">102 &#40;11&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">66 &#40;25&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">45 &#40;28&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8 &#40;29&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Team and social&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">23 &#40;1&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14 &#40;1&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5 &#40;1&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Communication&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">108 &#40;6&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">20 &#40;2&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12 &#40;4&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5 &#40;3&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Task related&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">126 &#40;7&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">83 &#40;9&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">30 &#40;11&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">10 &#40;6&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Training and education&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">228 &#40;14&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">162 &#40;18&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">33 &#40;12&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">23 &#40;14&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4 &#40;14&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Equipment and resources&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">189 &#40;11&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">30 &#40;3&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">24 &#40;9&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">20 &#40;12&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Working conditions&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">327 &#40;20&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">197 &#40;21&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">27 &#40;10&#46;42&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">34 &#40;21&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7 &#40;25&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Patient related&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">272 &#40;16&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">288 &#40;32&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">62 &#40;23&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">19 &#40;12&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8 &#40;29&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Total&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;627&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">896&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">259&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">156&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">27&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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        "descripcion" => array:1 [
          "en" => "<p id="spar0100" class="elsevierStyleSimplePara elsevierViewall">Distribution of the groups of contributing factors according to the reporting professional&#46;</p>"
        ]
      ]
      4 => array:7 [
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        "etiqueta" => "Table 4"
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        "mostrarFloat" => true
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0115" class="elsevierStyleSimplePara elsevierViewall">AE&#58; adverse event&#59; CF&#58; contributing factor&#59; NMI&#58; near-miss incident&#46;</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"><th class="td" title="table-head  " align="" valign="top" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Undoubtedly avoidable</th><th class="td" title="table-head  " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Possibly avoidable</th><th class="td" title="table-head  " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Possibly unavoidable</th><th class="td" title="table-head  " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Unavoidable</th><th class="td" title="table-head  " align="left" valign="top" scope="col">Total&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">n&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">n&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">n&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">n&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">n&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Professional&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">401&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">69&#46;74&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">154&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">26&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">17&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;96&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;52&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">575&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Team&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">31&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">73&#46;81&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">23&#46;81&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;38&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">42&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Communication&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">109&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">75&#46;17&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">32&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">22&#46;07&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;38&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;38&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">145&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Task&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">100&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">40&#46;16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">124&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">49&#46;80&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">17&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6&#46;83&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&#46;21&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">249&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Training and education&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">259&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">57&#46;56&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">181&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">40&#46;22&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">243&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">37&#46;44&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">49&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&#46;55&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">649&nbsp;\t\t\t\t\t\t\n
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        "texto" => "<p id="par0210" class="elsevierStylePara elsevierViewall">The authors thank the coordinators of the participating DICMs for the support given to this project&#46;</p> <p id="par0215" class="elsevierStylePara elsevierViewall">C&#225;novas Robles J&#44; Perales Pastor R&#44; HGU Alicante &#40;Alicante&#41;&#59; S&#225;nchez Ortega D&#44; Serrano Calvache JA&#44; H&#46; de Torrec&#225;rdenas &#40;Almer&#237;a&#41;&#59; de Rojas Rom&#225;n JP&#44; Ramos Carbonero Y&#44; H&#46; Comarcal de Antequera &#40;Antequera&#41;&#59; Guti&#233;rrez Fern&#225;ndez MJ&#44; Fern&#225;ndez &#193;lvarez V&#44; H&#46; San Agust&#237;n &#40;Avil&#233;s&#41;&#59; Umaran Sarachu MI&#44; Monguillo Martiregui MJ&#44; H&#46; de Cruces &#40;Baracaldo&#41;&#59; Fern&#225;ndez Dorado F&#44; Figueras Coloma E&#44; Centro M&#233;dico Delfos &#40;Barcelona&#41;&#59; Morillas P&#233;rez J&#44; Portillo Jaurena E&#44; SCIAS-H&#46; de Barcelona &#40;Barcelona&#41;&#59; S&#225;nchez Segura JM&#44; Sola Sole N&#44; H&#46; Santa Creu i Sant Pau &#40;Barcelona&#41;&#59; Zavala Zegarra E&#44; Cirerea A&#44; H&#46; Cl&#237;nic-UCI Quir&#250;rgica &#40;Barcelona&#41;&#59; V&#225;zquez S&#225;nchez A&#44; Abad Peruga V&#44; H&#46; del Mar &#40;Barcelona&#41;&#59; Robles Gonz&#225;lez A&#44; Borja Garc&#237;a MI&#44; H&#46; Vall d¿Hebron-Traumatolog&#237;a &#40;Barcelona&#41;&#59; Bellot Iglesias JL&#44; Mart&#237;nez Molina M&#44; H&#46; de Baza &#40;Baza&#41;&#59; Romero Pellerrejo J&#44; Campillo Temi&#241;o C&#44; Complejo Hospitalario de Burgos &#40;Burgos&#41;&#59; Mart&#237;nez Hern&#225;ndez J&#44; Alarc&#243;n Simarro N&#44; H&#46; Santa Mar&#237;a del Rosell &#40;Cartagena&#41;&#59; &#193;lvaro S&#225;nchez R&#44; Bernat Adell A&#44; H&#46; Universitario Asociado General de Castell&#243;n &#40;Castell&#243;n&#41;&#59; Molina Dom&#237;nguez E&#44; Ortega Carnicer J&#44; H&#46;G&#46; de Ciudad Real &#40;Ciudad Real&#41;&#59; Alcal&#225; L&#243;pez A&#44; Pastor M&#44; HGU de Elche &#40;Elche&#41;&#59; 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Reyes Garc&#237;a A&#44; Toledano Pe&#241;a J&#44; H&#46;U&#46; de la Princesa &#40;Madrid&#41;&#59; Ramos Polo J&#44; Suay Ojalvo C&#44; H&#46; Cl&#237;nico San Carlos &#40;Madrid&#41;&#59; Men&#233;ndez de Suso JJ&#44; Segovia Gait&#225;n M&#44; H&#46; San Rafael &#40;Madrid&#41;&#59; S&#225;enz Casco L&#44; Andr&#233;s Sarri&#225; M&#44; H&#46; Central de la Defensa G&#243;mez Ulla &#40;Madrid&#41;&#59; Jim&#233;nez Lend&#237;nez M&#44; Romero C&#44; H&#46;U&#46; La Paz &#40;Madrid&#41;&#59; Arias Verd&#250; MD&#44; Garc&#237;a Santana JL&#44; H&#46; Parque San Antonio &#40;M&#225;laga&#41;&#59; Arboleda S&#225;nchez JA&#44; Velasco Bueno JM&#44; H&#46; Costa del Sol &#40;Marbella&#41;&#59; Solsona Perlasia M&#44; Vilalta Llibre M&#44; Consorci Sanitari del Maresme &#40;CSdM&#41; &#40;Matar&#243;&#41;&#59; Garc&#237;a Fern&#225;ndez AM&#44; Morales Adeva L&#44; H&#46; de M&#233;rida &#40;M&#233;rida&#41;&#59; Galdos Anuncibay P&#44; Arias Castro I&#44; H&#46;G&#46; de M&#243;stoles &#40;M&#243;stoles&#41;&#59; G&#243;mez Ramos MJ&#44; Cevidanes M&#44; H&#46;G&#46;U&#46; Reina Sof&#237;a &#40;Murcia&#41;&#59; Mart&#237;nez Fresneda M&#44; Banacloche Cano C&#44; H&#46; Virgen de la Arrixaca &#40;Murcia&#41;&#59; Carrillo Alcaraz A&#44; Pe&#241;alver F&#44; H&#46; Morales Meseguer &#40;Murcia&#41;&#59; Iglesias Fraile L&#44; &#193;lvarez M&#233;ndez B&#44; H&#46;G&#46; de Asturias &#40;Oviedo&#41;&#59; Rialp Cervera G&#44; Bestard Soc&#237;as C&#44; H&#46; Son Ll&#224;tzer &#40;Palma de Mallorca&#41;&#59; Rodr&#237;guez Albarr&#225;n F&#44; Ballester Belcos R&#44; Cl&#237;nica San Miguel &#40;Pamplona&#41;&#59; Ramos Castro J&#44; Herranz Ayesa MV&#44; H&#46; Virgen del Camino &#40;Pamplona&#41;&#59; Mart&#237;nez Urionabarrenetxea K&#44; Elizondo Soto A&#44; H&#46; de Navarra &#40;Pamplona&#41;&#59; Gil Cebri&#225;n J&#44; Delgado Poullet N&#44; H&#46;U&#46; Puerto Real &#40;Puerto Real&#41;&#59; Prieto Valderrey F&#44; Nieto Galeano J&#44; H&#46; Santa B&#225;rbara &#40;Puertollano&#41;&#59; Rovira Angles C&#44; Cerrillo E&#44; H&#46;U&#46; Sant Joan de Reus &#40;Reus&#41;&#59; Dom&#237;nguez L&#243;pez S&#44; Malnero L&#243;pez M&#44; H&#46; Valle del Nal&#243;n &#40;Ria&#241;o&#41;&#59; Baigorri Gonz&#225;lez F&#44; Jam Gatell R&#44; H&#46; de Sabadell-Corporaci&#243; Parc Taul&#237; &#40;Sabadell&#41;&#59; Lacueva Moya V&#44; Hern&#225;ndez Santamar&#237;a F&#44; H&#46; de Sagunt &#40;Sagunto&#41;&#59; Gonz&#225;lez Robledo J&#44; Coca Hern&#225;ndez MA&#44; H&#46;U&#46; de Salamanca &#40;Salamanca&#41;&#59; Azk&#225;rate Ayerdi B&#44; Marcos A&#44; H&#46; Donostia &#40;San Sebasti&#225;n&#41;&#59; Rull Rodr&#237;guez VE&#44; Morras Pineda B&#44; Complejo Hospitalario de Soria-H&#46; de Santa B&#225;rbara &#40;Soria&#41;&#59; Gilavert Cuevas MC&#44; Aragon&#233;s M&#44; H&#46; Joan XXIII &#40;Tarragona&#41;&#59; Jurado Castro MT&#44; Bell Ribatallada M&#44; H&#46; de Terrasa &#40;Terrasa&#41;&#59; P&#233;rez-Pedrero S&#225;nchez-Belmonte MJ&#44; Pinilla L&#243;pez A&#44; H&#46; Virgen de la Salud &#40;Toledo&#41;&#59; V&#225;zquez Casas JR&#44; Herrero G&#243;mez E&#44; H&#46; Verge de la Cinta &#40;Tortosa&#41;&#59; Soto Ib&#225;&#241;ez JM&#44; Romero Mor&#225;n MA&#44; H&#46;U&#46; Dr&#46; Peset &#40;Valencia&#41;&#59; Garc&#237;a Galiana E&#44; Fern&#225;ndez Mart&#237;nez A&#44; Fundaci&#243;n Instituto Valenciano de Oncolog&#237;a &#40;Valencia&#41;&#59; Dom&#237;nguez Quintero LA&#44; Acebes Sancho BE&#44; Dom&#237;nguez Quintero LA&#44; Palencia Garc&#237;a MA&#44; H&#46; R&#237;o Hortega-Polivalente &#40;Valladolid&#41;&#59; Tiz&#243;n Varela AI&#44; de Castro Rodr&#237;guez P&#44; Complexo Hospitalario Universitario de Vigo-H&#46; Xeral C&#237;es &#40;Vigo&#41;&#59; Manzano Ram&#237;rez A&#44; Ruiz de Ofenda E&#44; H&#46; Santiago Ap&#243;stol &#40;Vitoria&#41;&#59; Marcos Guti&#233;rrez A&#44; Larruscain Le&#243;n MV&#44; H&#46; Virgen de la Concha &#40;Zamora&#41;&#59; Temi&#241;o Palomera S&#44; Lasheras Palomero L&#44; Mutua de Accidentes de Zaragoza &#40;Zaragoza&#41;&#59; Guti&#233;rrez C&#237;a I&#44; Moreno MA&#44; H&#46; Cl&#237;nico Universitario Lozano Blesa-UCI Quir&#250;rgica &#40;Zaragoza&#41;&#59; Tirado Angles G&#44; Gonz&#225;lez Caballero M&#44; H&#46; Royo Villanova &#40;Zaragoza&#41;&#59; Valero Garc&#237;a R&#44; Casa Venta J&#44; H&#46;U&#46; Miguel Servet-Coronaria &#40;Zaragoza&#41;&#59; Garc&#237;a Mangas P&#44; Mahave Carrasco R&#44; H&#46;U&#46; Miguel Servet-Polivalente &#40;Zaragoza&#41;&#59; Olmos P&#233;rez F&#44; Villabona Resano J&#44; H&#46;U&#46; Miguel Servet-Cirug&#237;a Cardiaca &#40;Zaragoza&#41;&#59; Williams L&#44; Pati&#241;o Y&#44; Centro de Especialidades Anzo&#225;tegui&#44; Lecher&#237;a &#40;Venezuela&#41;&#59; Margarit Ribas A&#44; Flamarique Zaratiegui MT&#44; H&#46; Nostra Senyora de Meritxell&#44; Escaldes-Engordany &#40;Andorra&#41;&#59; Ortega RA&#44; S&#225;nchez Reinoso J&#44; San Juan Bautista&#44; Catamarca &#40;Argentina&#41;&#59; Diosdado Iraola Ferrer M&#44; Mora P&#233;rez Y&#44; H&#46;U&#46; Dr&#46; 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Article information

ISSN: 21735727
Original language: English

DOI:10.1016/j.medine.2015.05.001

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2024 November	8	10	18
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2023 May	67	32	99
2023 April	61	26	87
2023 March	80	37	117
2023 February	74	38	112
2023 January	54	30	84
2022 December	86	28	114
2022 November	100	40	140
2022 October	66	27	93
2022 September	55	33	88
2022 August	75	44	119
2022 July	61	36	97
2022 June	64	25	89
2022 May	53	45	98
2022 April	69	40	109
2022 March	93	52	145
2022 February	74	39	113
2022 January	105	51	156
2021 December	89	52	141
2021 November	74	49	123
2021 October	114	61	175
2021 September	65	45	110
2021 August	85	28	113
2021 July	62	44	106
2021 June	47	28	75
2021 May	89	39	128
2021 April	230	145	375
2021 March	204	28	232
2021 February	133	25	158
2021 January	121	26	147
2020 December	101	31	132
2020 November	91	36	127
2020 October	91	22	113
2020 September	119	26	145
2020 August	84	15	99
2020 July	83	26	109
2020 June	84	23	107
2020 May	91	11	102
2020 April	127	20	147
2020 March	180	20	200
2020 February	291	39	330
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2019 December	154	15	169
2019 November	158	35	193
2019 October	58	26	84
2019 September	75	31	106
2019 August	78	32	110
2019 July	59	31	90
2019 June	52	12	64
2019 May	93	38	131
2019 April	71	28	99
2019 March	46	27	73
2019 February	45	37	82
2019 January	43	28	71
2018 December	69	51	120
2018 November	158	66	224
2018 October	142	27	169
2018 September	73	11	84
2018 August	53	4	57
2018 July	35	7	42
2018 June	44	10	54
2018 May	37	7	44
2018 April	90	5	95
2018 March	72	2	74
2018 February	118	9	127
2018 January	84	9	93
2017 December	137	5	142
2017 November	26	8	34
2017 October	27	7	34
2017 September	18	8	26
2017 August	16	7	23
2017 July	20	8	28
2017 June	40	15	55
2017 May	26	7	33
2017 April	27	10	37
2017 March	11	2	13
2017 February	10	7	17
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2016 October	63	9	72
2016 September	49	12	61
2016 August	70	10	80
2016 July	30	6	36
2016 May	1	0	1
2016 March	1	0	1
2015 December	2	0	2

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