Letter to the Editor
Failure mode and effect analysis applied to the procedure for intrathecal chemotherapy
Análisis de modos de fallo y sus efectos aplicado al procedimiento de quimioterapia intratecal
P. de la Riva
, M.T. Martinez Zabaleta, M. Arruti González, M.A. Urtasun Ocariz
Corresponding author
Servicio de Neurología, Hospital Donostia, San Sebastián, Guipúzcoa, Spain
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Arrows indicate the links between clinical syndromes and underlying disease, while continuous lines show the most robust associations. The most frequent histopathological subtype is listed for each syndrome. FTD: frontotemporal dementia; FTLD: frontotemporal lobar degeneration; PSPS: progressive supranuclear palsy syndrome; CBS: corticobasal syndrome; PNFA: progressive nonfluent aphasia; bv-FTD: behavioural variant frontotemporal dementia; SD: semantic dementia; FTD-MND: frontotemporal dementia associated with motor neuron disease; PSP: progressive supranuclear palsy; CBD: corticobasal degeneration; PiD: Pick disease; MAPT: microtubule associated protein tau; FUS: fused-in sarcoma protein; PGRN: progranulin; VCP: valosin containing protein; TARDBP: TAR DNA-binding protein 43; CHMP2B: charged multivesicular body protein 2B. FTLD-TDP subtypes 1-3 are designated according to Mackenzie's classification.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "M. Fernández-Matarrubia, J.A. Matías-Guiu, T. Moreno-Ramos, J. Matías-Guiu" "autores" => array:4 [ 0 => array:2 [ "nombre" => "M." "apellidos" => "Fernández-Matarrubia" ] 1 => array:2 [ "nombre" => "J.A." "apellidos" => "Matías-Guiu" ] 2 => array:2 [ "nombre" => "T." "apellidos" => "Moreno-Ramos" ] 3 => array:2 [ "nombre" => "J." "apellidos" => "Matías-Guiu" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0213485313000674" "doi" => "10.1016/j.nrl.2013.03.002" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0213485313000674?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173580814001540?idApp=UINPBA00004N" "url" => "/21735808/0000003000000001/v2_201706020304/S2173580814001540/v2_201706020304/en/main.assets" ] "en" => array:15 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>" "titulo" => "Failure mode and effect analysis applied to the procedure for intrathecal chemotherapy" "tieneTextoCompleto" => true "saludo" => "Dear Editor:" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "62" "paginaFinal" => "64" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "P. de la Riva, M.T. Martinez Zabaleta, M. Arruti González, M.A. Urtasun Ocariz" "autores" => array:4 [ 0 => array:4 [ "nombre" => "P." "apellidos" => "de la Riva" "email" => array:1 [ 0 => "patricia.delariva@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "M.T." "apellidos" => "Martinez Zabaleta" ] 2 => array:2 [ "nombre" => "M." "apellidos" => "Arruti González" ] 3 => array:2 [ "nombre" => "M.A." "apellidos" => "Urtasun Ocariz" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Neurología, Hospital Donostia, San Sebastián, Guipúzcoa, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Análisis de modos de fallo y sus efectos aplicado al procedimiento de quimioterapia intratecal" ] ] "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" => 298 "Ancho" => 2289 "Tamanyo" => 39608 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Diagram of intrathecal chemotherapy process.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The purpose of this letter is to present failure mode and effects analysis (FMEA), a tool with clinical safety applications that may be useful for minimising risks associated with healthcare procedures. We also describe our experience with applying FMEA to intrathecal chemotherapy at Hospital Universitario Donostia.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Intrathecal chemotherapy is an invasive procedure associated with numerous adverse events, many of which may be caused by human error.</p><p id="par0015" class="elsevierStylePara elsevierViewall">At Hospital Universitario Donostia, intrathecal chemotherapy has traditionally been prescribed and ordered by haematology or oncology departments, whereas the neurology department is responsible for administering the treatment. Since there have been several severe incidents related to intrathecal chemotherapy, we recently decided to find a way to minimise the risks associated with this procedure.</p><p id="par0020" class="elsevierStylePara elsevierViewall">FMEA was performed according to the following steps:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1.</span><p id="par0025" class="elsevierStylePara elsevierViewall">Select a high-risk process. The chosen process was intrathecal chemotherapy.</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2.</span><p id="par0030" class="elsevierStylePara elsevierViewall">Assemble a team. We gathered a multidisciplinary work team, including doctors and nurses familiar with intrathecal chemotherapy from the haematology, oncology, pharmacy, neurology, and quality control departments.</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3.</span><p id="par0035" class="elsevierStylePara elsevierViewall">Describe the process. We designed a diagram describing the different steps in the process and how they are interrelated (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">4.</span><p id="par0040" class="elsevierStylePara elsevierViewall">Analyse risk. Team members brainstormed to list different possible ways in which each sub-process might fail. Next, cause, effect, and detection method for each failure mode were identified and rated for frequency, severity, and detectability on scales of 1 to 10. Finally, total risk for each failure mode was calculated by multiplying the values of these 3 factors (frequency, severity, and detectability) to give the risk priority number (RPN). As an example, <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows the model sheet used to collect risk analysis data for the sub-process of administering the drug.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">5.</span><p id="par0045" class="elsevierStylePara elsevierViewall">Propose improvements and monitor implementation of the redesigned process. A total of 10 improvement actions were defined, with priority given to failure modes with higher RPNs. We also decided which team members would be responsible for implementing each new process (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).</p></li></ul></p><p id="par0050" class="elsevierStylePara elsevierViewall">Twenty-eight months after implementing improvements, 141 intrathecal chemotherapy procedures have been performed in a total of 38 patients and no incidents have been detected.</p><p id="par0055" class="elsevierStylePara elsevierViewall">FMEA is a tool enabling systematic and prospective identification and prevention of the risks associated with a process. This technique has been widely used not only in healthcare but also in the aerospace and automotive industries.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">In addition to identifying and preventing failures that already occur or may potentially occur, it enables sharing experiences with different units participating in the same process. It is also recommended by several national and international health organisations.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">However, some of the main limitations of FMEA are the absence of studies verifying its validity or utility, its reliance on team members’ previous experiences, the mathematically flawed way in which RPN is calculated, and the fact that costs and healthcare available resources are not taken into consideration.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">In conclusion, FMEA is a useful tool since it provides an organised and systematic method which can help resolve failure modes that involve several professionals taking part in a single process.</p><p id="par0075" class="elsevierStylePara elsevierViewall">In addition to intrathecal chemotherapy, neurology departments currently perform many other invasive procedures whose safety could be increased by using this technique. Examples include immunoglobulin administration, plasmapheresis sessions, and intravenous administration of antibiotics or immunosupressants.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:2 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: de la Riva P, Martinez Zabaleta MT, Arruti González M, Urtasun Ocariz MA. Análisis de modos de fallo y sus efectos aplicado al procedimiento de quimioterapia intratecal. Neurología. 2015;30:62–64.</p>" ] 1 => array:2 [ "etiqueta" => "☆☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">This study was presented orally, under the same title, at the 64th Annual Meeting of the Spanish Society of Neurology.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 298 "Ancho" => 2289 "Tamanyo" => 39608 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Diagram of intrathecal chemotherapy process.</p>" ] ] 1 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "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">Failure mode \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">Effect \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">Cause \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">Detection method \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">Severity \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">Frequency \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">Detectability \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">Initial RPN \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">Recommended actions \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">Responsible department \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">Delay in drug administration \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Lack of effectiveness \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No care pathway \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Nurse/patient \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">8 \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">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Establishing a care pathway \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Neurology \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="3" align="left" valign="top">Wrong medication</td><td class="td" title="table-entry " align="left" valign="top">Toxicity \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No care pathway \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Nurse/doctor \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">1 \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">80 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Establishing a care pathway \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Neurology \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">Toxicity \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Administration route not verified \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Nurse/doctor \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">2 \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">160 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Use of minibags \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Pharmacy \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">Toxicity \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Similar drug package \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Nurse \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">5 \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">300 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Container specific to intrathecal drugs labelled ‘for intrathecal use only’ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Pharmacy \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">Drug not indicated \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Toxicity/lack of effectiveness \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Lack of communication/workload problem \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Nurse/doctor \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">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">140 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Electronic prescription \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Quality control \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="2" align="left" valign="top">Inappropriate technique</td><td class="td" title="table-entry " align="left" valign="top">Puncture-related complications \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Not verifying patient's state (laboratory analyses, anticoagulants) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Nurse/doctor \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">2 \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">160 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Implementing checklist prior to administration \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Neurology, nursing staff \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">Puncture-related complications \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Doctor's lack of experience \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Nurse/doctor \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">2 \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">160 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Establishing a care pathway \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Neurology \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 identification \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Toxicity/reduced effectiveness \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Not verifying patient data \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Nurse/doctor/patient \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">1 \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">100 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Implementing checklist prior to administration \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" 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">Not checking patient's lab analyses \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Complications \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Puncture contraindicated because of analysis results or anticoagulant treatment \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Nurse/doctor \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">2 \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">160 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Implementing checklist prior to administration \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Neurology, nursing staff \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1431796.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Risk analysis table for the administration sub-process in intrathecal chemotherapy.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:4 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:3 [ "comentario" => "209" "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Using health care failure mode and effect analysis: the VA National Center for Patient Safety's prospective risk analysis system" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "J. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 6 | 0 | 6 |
| 2024 October | 29 | 3 | 32 |
| 2024 September | 39 | 9 | 48 |
| 2024 August | 36 | 12 | 48 |
| 2024 July | 27 | 4 | 31 |
| 2024 June | 16 | 8 | 24 |
| 2024 May | 16 | 4 | 20 |
| 2024 April | 21 | 4 | 25 |
| 2024 March | 34 | 8 | 42 |
| 2024 February | 43 | 8 | 51 |
| 2024 January | 36 | 6 | 42 |
| 2023 December | 53 | 12 | 65 |
| 2023 November | 37 | 10 | 47 |
| 2023 October | 27 | 15 | 42 |
| 2023 September | 18 | 6 | 24 |
| 2023 August | 18 | 4 | 22 |
| 2023 July | 15 | 9 | 24 |
| 2023 June | 23 | 3 | 26 |
| 2023 May | 60 | 4 | 64 |
| 2023 April | 36 | 4 | 40 |
| 2023 March | 30 | 2 | 32 |
| 2023 February | 28 | 8 | 36 |
| 2023 January | 13 | 4 | 17 |
| 2022 December | 20 | 7 | 27 |
| 2022 November | 35 | 9 | 44 |
| 2022 October | 21 | 13 | 34 |
| 2022 September | 32 | 8 | 40 |
| 2022 August | 17 | 9 | 26 |
| 2022 July | 28 | 6 | 34 |
| 2022 June | 25 | 10 | 35 |
| 2022 May | 30 | 9 | 39 |
| 2022 April | 26 | 9 | 35 |
| 2022 March | 39 | 17 | 56 |
| 2022 February | 25 | 8 | 33 |
| 2022 January | 40 | 19 | 59 |
| 2021 December | 22 | 20 | 42 |
| 2021 November | 63 | 8 | 71 |
| 2021 October | 53 | 17 | 70 |
| 2021 September | 29 | 18 | 47 |
| 2021 August | 18 | 9 | 27 |
| 2021 July | 18 | 13 | 31 |
| 2021 June | 21 | 16 | 37 |
| 2021 May | 27 | 8 | 35 |
| 2021 April | 59 | 17 | 76 |
| 2021 March | 68 | 11 | 79 |
| 2021 February | 36 | 13 | 49 |
| 2021 January | 44 | 11 | 55 |
| 2020 December | 32 | 8 | 40 |
| 2020 November | 31 | 15 | 46 |
| 2020 October | 33 | 3 | 36 |
| 2020 September | 27 | 16 | 43 |
| 2020 August | 24 | 8 | 32 |
| 2020 July | 26 | 15 | 41 |
| 2020 June | 22 | 11 | 33 |
| 2020 May | 26 | 14 | 40 |
| 2020 April | 29 | 8 | 37 |
| 2020 March | 32 | 7 | 39 |
| 2020 February | 25 | 7 | 32 |
| 2020 January | 28 | 5 | 33 |
| 2019 December | 61 | 7 | 68 |
| 2019 November | 40 | 13 | 53 |
| 2019 October | 38 | 5 | 43 |
| 2019 September | 46 | 6 | 52 |
| 2019 August | 21 | 6 | 27 |
| 2019 July | 28 | 11 | 39 |
| 2019 June | 61 | 13 | 74 |
| 2019 May | 125 | 28 | 153 |
| 2019 April | 67 | 16 | 83 |
| 2019 March | 25 | 4 | 29 |
| 2019 February | 19 | 4 | 23 |
| 2019 January | 20 | 7 | 27 |
| 2018 December | 11 | 1 | 12 |
| 2018 November | 30 | 9 | 39 |
| 2018 October | 23 | 11 | 34 |
| 2018 September | 25 | 6 | 31 |
| 2018 August | 7 | 0 | 7 |
| 2018 July | 4 | 1 | 5 |
| 2018 June | 7 | 4 | 11 |
| 2018 May | 9 | 5 | 14 |
| 2018 April | 7 | 1 | 8 |
| 2018 March | 14 | 3 | 17 |
| 2018 February | 4 | 0 | 4 |
| 2018 January | 10 | 2 | 12 |
| 2017 December | 13 | 1 | 14 |
| 2017 November | 13 | 3 | 16 |
| 2017 October | 12 | 0 | 12 |
| 2017 September | 11 | 3 | 14 |
| 2017 August | 23 | 5 | 28 |
| 2017 July | 14 | 3 | 17 |
| 2017 June | 15 | 13 | 28 |
| 2017 May | 14 | 5 | 19 |
| 2017 April | 29 | 4 | 33 |
| 2017 March | 35 | 66 | 101 |
| 2017 February | 17 | 2 | 19 |
| 2017 January | 12 | 2 | 14 |
| 2016 December | 11 | 9 | 20 |
| 2016 November | 22 | 6 | 28 |
| 2016 October | 22 | 8 | 30 |
| 2016 September | 30 | 8 | 38 |
| 2016 August | 15 | 4 | 19 |
| 2016 July | 25 | 3 | 28 |
| 2016 June | 40 | 15 | 55 |
| 2016 May | 22 | 14 | 36 |
| 2016 April | 37 | 19 | 56 |
| 2016 March | 42 | 26 | 68 |
| 2016 February | 17 | 13 | 30 |
| 2016 January | 16 | 10 | 26 |
| 2015 December | 9 | 13 | 22 |
| 2015 November | 24 | 6 | 30 |
| 2015 October | 24 | 13 | 37 |
| 2015 September | 24 | 8 | 32 |
| 2015 August | 19 | 1 | 20 |
| 2015 July | 18 | 5 | 23 |
| 2015 June | 12 | 11 | 23 |
| 2015 May | 17 | 6 | 23 |
| 2015 April | 22 | 14 | 36 |
| 2015 March | 35 | 6 | 41 |
| 2015 February | 83 | 32 | 115 |
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