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Fulltext A 2-year audit of perioperative mortality in Malaysian hospitals

Inbasegaran K, Kandasami P, Sivalingam N

Med J Malaysia, 1998 Dec;53(4):334-42.
PMID: 10971975

An audit of all perioperative deaths within seven days of surgery in 14 major public hospitals is presented. This study is part of a quality assurance programme examining the surgical and anaesthetic practices in these hospitals. During the study period from July 1992 till June 1994, 211,354 surgeries were performed and 715 deaths were reported out of which 699 were available for analysis. The data was obtained by confidential enquiry using predetermined questionnaires filled by participating surgeons and anaesthetists and analysed by a group of peers. The overall crude mortality rate was 0.34% and the majority of the deaths occurred in severely ill patients in whom the clinical management was satisfactory. Polytrauma including head, intra-abdominal and skeletal trauma accounted for 253 of the deaths (36.19%). The other causes were bowel obstruction with sepsis, burns, ischaemic limbs, congenital malformations in neonates and pregnancy-related hemorrhage. 62.52% of the deaths occurred within two days of surgery and 85.87% were related to emergency procedures. The review identified some shortfalls in perioperative care and these were lack of adequate critical care facilities, lack of supervision, unnecessary surgery in the moribund and inadequate preoperative optimisation. The results of the study have been forwarded to all participating hospitals for implementation of remedial measures.

Matched MeSH terms: Medical Audit*
Fulltext A 3 year audit of infected pseudoaneurysms in intravenous drug users managed surgically in the Vascular Unit, Hospital Kuala Lumpur

Zainal AA, Yusha AW

Med J Malaysia, 1998 Dec;53(4):372-5.
PMID: 10971980

This is a study of 54 intravenous drug user's (IVDUs) with infected pseudoaneurysms undergoing ligation and debridement at the Vascular Unit, Hospital Kuala Lumpur (HKL) from February 1993 to February 1996. The median age was 37 years with a male preponderance (53:1). Chinese form the largest ethnic group with 57.4% of the cases. Staphylococcus aureus was the most common organism cultured. Human immunodeficiency virus (HIV) positive cases numbered 21 (38.9%). Four of the patients had to have an above-knee amputation after surgery. Simple ligation and debridement of all necrotic tissue is an acceptable mode of therapy in these patients with low amputation rates.

Matched MeSH terms: Medical Audit*
Fulltext A clinical audit on diabetes care in two urban public primary care clinics in Malaysia

Sazlina SG, Zailinawati AH, Zaiton A, Ong I

Malaysian Journal of Medicine and Health Sciences, 2010;6(1):101-109.
MyJurnal

Introduction: The incidence of diabetes mellitus (DM) is increasing globally and it is associated with significant morbidity and mortality. The importance of a better quality of diabetes care is increasingly acknowledged. Objective: This clinical audit was conducted to assess the quality of care given to type 2 DM patients in public primary care clinics. Methods: A clinical audit was conducted in two selected urban public primary care clinics, between April and June of 2005. The indicators and criteria of quality care were based on the current Malaysian clinical practice guidelines for type 2 DM. A structured pro forma was used to collect data. Results: A total of 396 medical records of patients with type 2 DM were included in this audit. Most of the patients had measurements of fasting blood glucose and blood pressure recorded in more than 90% of the visits over the previous one year. Twenty-seven percent of the patients had glycosylated haemoglobin (HbA1c) done every 6 months with a mean of 8.3%. Only 15.6% had HbA1c values less than 6.5 %. Fifty percent had blood pressure controlled at 130/80 mmHg and below; and 13.0% had low density lipoprotein cholesterol values of 2.6 mmol/L or less. The majority of the patients were overweight or obese. Conclusions: The quality of diabetes care in this study was
found to be suboptimal. There is a gap between guidelines and clinical practice. Certain measures to improve the quality of diabetes care need to be implemented with more rigour.

Matched MeSH terms: Medical Audit*
Fulltext A clinical audit on the care of adult tuberculosis contacts In a public primary care clinic, Malaysia

Ching SM, Hassan F, Paimin F

Malaysian Journal of Medicine and Health Sciences, 2015;11(1):19-25.
MyJurnal

The National Clinical Practice Guideline in Tuberculosis (TB) was designed to improve the quality of tuberculosis care. However, it remains unknown whether primary care doctors adhere to it well. This audit aims to assess the quality of care in the process of TB contact tracing in a primary care setting. Methods: Data on TB contact tracing from 1st February 2013 to 15th February 2013 was obtained retrospectively from all medical records of diagnosed pulmonary TB in a public primary care clinic. All patients who fulfilled the inclusion and exclusion criteria were included in the study. Results: A total of 102 medical records of adult TB contacts were recruited. The median age of the TB contact was 34 (IQR=10) years and 65 % were male. Seventy two percent of the adult TB contact had a TBIS 10C3 form created, and 95% of the medical records were fully documented. History taking and physical examination were recorded on 97% and 99% of patients respectively during the first follow-up at the polyclinic. Eighty five percent and 100% of the patients had a chest-x-ray and sputum direct smear for acid-fast bacilli done respectively. The turn-up rate for the first, second, third and fourth visit was 100% to 32%, 10% and 2% respectively. Conclusion: The quality of care for adult TB contacts tracing in this clinical audit was found to be suboptimal. There is a difference between the current national guidelines and practice in the clinic. Certain measures to improve the quality of care for adult TB contact tracing
are urgently needed.

Matched MeSH terms: Medical Audit
A comparison of dabigatran and warfarin for stroke prevention in elderly Asian population with nonvalvular atrial fibrillation: An audit of current practice in Malaysia

Yap SH, Ng YP, Roslan A, Kolanthaivelu J, Koh KW, P'ng HS, et al.

Med J Malaysia, 2017 12;72(6):360-364.
PMID: 29308774 MyJurnal

INTRODUCTION: Atrial fibrillation (AF) is the most common cardiac arrhythmia with significant morbidity and mortality in relation to thromboembolic stroke. Our study aimed to evaluate the safety and efficacy of dabigatran in stroke prevention in elderly patient with nonvalvular AF with regard to the risk of ischemic stroke and intracranial haemorrhage (ICH) in real-world setting.
METHODS: A retrospective cohort study of 200 patients on dabigatran and warfarin from January 2009 till September 2016 was carried out. Data were collected for 100 patients on dabigatran and 100 patients on warfarin.
RESULTS: The mean follow-up period was 340.7±322.3 days for dabigatran group and 410.5±321.2 days for warfarin group. The mean time in therapeutic range (TTR) was 52±18.7%. The mean CHA2DS2 -VASc score for dabigatran group was 4.4±1.1 while 5.0±1.5 for warfarin group. None in dabigatran group experienced ischemic stroke compared to one patient in warfarin group (p=0.316). There was one patient in dabigatran group suffered from ICH compared to none in warfarin group (p=0.316). Four patients in warfarin group experienced minor bleeding, while none from dabigatran group (p=0.043).
CONCLUSION: Overall bleeding events were significantly lower in dabigatran group compared to warfarin group. In the presence of suboptimal TTR rates and inconveniences with warfarin therapy, non-vitamin-K antagonist oral anticoagulants (NOAC) are the preferred agents for stroke prevention in elderly Asian patients for nonvalvular AF.

Matched MeSH terms: Medical Audit
Fulltext A hospital based audit of tuberculosis deaths

Hooi LN, Goh KY

Med J Malaysia, 1995 Dec;50(4):306-13.
PMID: 8668048

An audit was done on 54 tuberculosis patients presenting to Penang Hospital who died during 1993. Active tuberculosis was the cause of death in 29 (53.7%) and 48.3% were aged under 50 years. Tuberculosis was a contributory cause of death in 8 patients and in 17 patients tuberculosis was irrelevant to the cause of death. The diagnosis of tuberculosis was made after death in 17 patients (31.5%). Late diagnosis was the most important factor resulting in death. Only 41.4% of the deaths from active tuberculosis were correctly certified in government hospitals. Medically inspected and certified deaths from tuberculosis is an unreliable indicator of tuberculosis mortality because of inaccuracies in death certification, tuberculosis deaths occurring outside hospital and tuberculosis patients undiagnosed until after death.

Matched MeSH terms: Medical Audit
A prospective audit of Desflurane anaesthesia in the University of Malaya Medical Centre Day Surgery Unit

Chiu CL, Mansor M, Wang CY

JUMMEC, 2005;8:45-49.

We evaluated the use of Desflurane anaesthesia in this prospective observational audit in the University of Malaya Medical Centre Day Surgery Unit. Fifty ASA I-II unpremedicated day surgery patients received fentanyl and propofol induction after preoxygenation. Desflurane was introduced initially at 2% and the concentration was increased gradually to 4%, then 6%, 8% and 10% in nitrous oxide and oxygen. Patients breathed spontaneously throughout the surgery. Desflurane was switched off at the end of surgery and patients breathed 100% oxygen. The haemodynamic effect, perioperative complications and recovery profiles were recorded. Systolic arterial pressure and heart rate decreased after induction of anaesthesia but returned to baseline value at discharge. Adverse airway event such as coughing and postoperative nausea and vomiting are two unwanted complications. KEYWORDS: Desflurane, day surgery, propofol induction

Matched MeSH terms: Medical Audit
Fulltext A review of dengue fever incidence in Kota Bharu, Kelantan, Malaysia during the years 1998-2003

Hussin N, Jaafar J, Naing NN, Mat HA, Muhamad AH, Mamat MN

Southeast Asian J. Trop. Med. Public Health, 2005 Sep;36(5):1179-86.
PMID: 16438143

Dengue is the most common and widespread arthropod borne arboviral infection in the world today. It is estimated that there are at least 100 million cases of dengue fever (DF) annually and 500,000 cases of dengue hemorrhagic fever (DHF) which require hospitalization. In Malaysia, it has become a major public health problem. Malaysia recorded 19,544 dengue cases in 1997, the highest recorded since the disease was made notifiable in the country. Of 19,544 cases, 806 were DHF with 50 deaths. The objectives of this analysis were to describe the incidence of dengue fever and dengue hemorrhagic fever in Kota Bharu, Kelantan, Malaysia for the years 1998-2003 and to explore the characteristics of dengue fever and dengue hemorrhagic fever in Kota Bharu, Kelantan, Malaysia for years 1998-2003. A total of 4,716 dengue cases were notified involving 4,476 (94.9%) DF and 240 (5.1%) DHF cases, which increased though the years. The highest incidence was in January (701 or 14.9%), while the lowest was in May (188 or 4.0%). Forty percent of cases (n=1,890) were in the 15-29 year old group. The Majority were Malays (4,062 or 86.1%) and 2,602 or 55.2% were male. A total of 4,477 cases (95%) were local cases and 4,289 or 91% came from the urban area. For priority areas, 3,772 (80%) were from priority 1. More than half the cases had positive serology results. All symptoms occurred in more than 96% of cases and fever was the commonest (99.7%). The mean values for age, temperature, systolic and diastolic blood pressure (BP) were 27.8 +/- 15.4 years, 37.9 +/- 0.90 degrees C, 115 +/- 15.2 mmHg and 73 +/- 11.1 mmHg, respectively. The mean value for the time interval between the onset of symptoms and diagnosis, onset of symptoms and notification and time of diagnosis to notification were 5.1 +/- 2.3, 5.9 +/- 2.5 and 0.8 +/- 1.1 days, respectively. There were associations between the types of dengue and classification, area and priority area. Among the symptoms, the association was only seen in joint pain. The mean significant differences between DF and DHF were found in age and systolic blood pressure. The incidence of dengue in Kota Bharu is comparable to that in Malaysia. The increase in the number of cases needs to be addressed promptly with effective surveillance, prevention and control programs.

Matched MeSH terms: Medical Audit
A study of the appropriateness of antibiotic use in the medical wards of a tertiary teaching hospital in Malaysia

Hooi PY, Yong CM, Cheong I

Int J Clin Pract, 2001 May;55(4):272-4.
PMID: 11406914

A prospective study was conducted to determine the proportion of patients who received an antibiotic within 12 hours of admission to the medical wards. During the four-week study, 234 patients were admitted to medical wards from casualty; 68 patients (29%) received an antibiotic. The survey indicated that antibiotics were inappropriate in 22-65% of those treated. This study also shows that as many as 67% of patients who received intravenous antibiotics could have been equally well treated with oral preparations.

Matched MeSH terms: Medical Audit
Fulltext A study on the adequacy of outpatient management of essential hypertension in MOH hospitals and health centres

Mohd Ghazali RJ

ISBN: 983-3038-10-7

Citation: Mohd Ghazali RJ. A study on the adequacy of outpatient management of essential hypertension in MOH hospitals and health centres. Kuala Lumpur: Institute of Health Management, Ministry of Health, Malaysia; 2006

Matched MeSH terms: Medical Audit
A thermoluminescent dosimetry postal dose inter-comparison of radiation therapy centres in Malaysia

Rassiah P, Ng KH, DeWerd LA, Kunugi K

Australas Phys Eng Sci Med, 2004 Mar;27(1):25-9.
PMID: 15156705

A thermoluminescent dosimetry (TLD) postal dose inter-comparison was carried out amongst radiotherapy centres in Malaysia. The aim of this TLD inter-comparison was to compare the uniformity involved in the measurement of absorbed dose among the participating centres. A set of 5 TLD chips placed within acrylic trays were mailed to all participating centres for irradiation to an absorbed dose to water of 2 Gy. Measurements were made for 6 MV and 60Co photon beams. Results show an agreement of +/- 5% for all but three radiotherapy centres. The ratios of the TLD readings to that of the reference centre are comparable with other national/regional dose inter-comparisons. The importance of a proper ongoing quality assurance program is essential in maintaining the consistency and uniformity of doses delivered.

Matched MeSH terms: Medical Audit/methods; Medical Audit/standards*
Adverse hospital outcomes associated with the choice of empiric antibiotics in Klebsiella pneumoniae pneumonia: a retrospective observational study

Loh LC, Rosdara Masayuni MS, Nor Izran Hanim AS, Raman S, Thayaparan T, Kumar S

Ann Acad Med Singap, 2007 Aug;36(8):642-6.
PMID: 17767334

INTRODUCTION: In Malaysia, Klebsiella pneumoniae ranks high as a cause of adult pneumonia requiring hospitalisation.
PATIENTS AND METHODS: With concern over its rising microbial resistance, we explored the association of empiric antibiotics choices with the hospital outcomes of patients treated for microbial proven K. pneumoniae pneumonia in an urban-based teaching hospital.
RESULTS: In 313 eligible cases reviewed retrospectively, hospital mortality and requirement for ventilation were 14.3% and 10.8% respectively. Empiric regimes that had in vitro resistance to at least one empiric antibiotic (n = 90) were associated with higher hospital mortality (23.3% vs. 10.8%, P = 0.004) with risk increased by about two-fold [Odds ratio (OR), 2.5; 95% confidence interval (CI), 1.3 to 4.8]. Regimes (n = 84) other than the commonly recommended "standard" regimes (a beta-lactam stable antibiotic with or without a acrolide) were associated with higher ventilation rates (16.7% vs. 8.8%, P = 0.047) with similar increased risk [OR, 2.0; 95% CI, 1.0 to 4.3].
CONCLUSIONS: Our findings reiterate the clinical relevance of in vitro microbial resistance in adult K. pneumoniae pneumonia and support empiric regimes that contain beta-lactam stable antibiotics.

Matched MeSH terms: Medical Audit
Fulltext An Audit of Diabetes Control and Management (ADCM)

Mastura I, Zanariah H, Fatanah I, Feisul Idzwan M, Wan Shaariah MY, Jamaiyah H, et al.

Med J Malaysia, 2008 Sep;63 Suppl C:76-7.
PMID: 19227679

Diabetes is a chronic condition that is one of the major causes of illness, disability, and death in Malaysia. Cost in managing diabetes plus indirect cost of lost work, pain, and suffering have all increased. The optimal management of patients with diabetes require the tracking of patients over time to monitor the progression of the disease, compliance with treatment, and preventive care. Diabetes care can be improved by standardizing access to, and improving the use of, clinical information. Access to timely, accurate and well-organized electronic data will improve the quality of care for patients with diabetes. Clinical Research Center convened an expert workshop to forecast how physicians, hospitals and clinics will employ clinical information technology (IT) applications to diabetes care over the next year. Workshop participants included experts from research organizations, government, and the IT vendor. This is a summary of the workshop organised for the purpose of the Audit of Diabetes Control and Management (ADCM) project. We hope to identify the gaps, if any, that exists in delivering diabetes care and to improve the quality of care. In future, we hope to develop an expansion of this project for the Adult Diabetes Registry that will be implemented for the whole country.

Matched MeSH terms: Medical Audit*
Fulltext An annual audit of the ear foreign bodies in Hospital Universiti Sains Malaysia

Yaroko AA, Irfan M

Malays Fam Physician, 2012;7(1):2-5.
PMID: 25606237 MyJurnal

Foreign bodies or objects in the ear are one of the most common problems encountered by otorhinolaryngologist (ORL) with attendant complications, removal of which requires expertise. Patients with this problem who sought treatment in the otorhinolaryngology clinic of Hospital Universiti Sains Malaysia (HUSM) were studied for duration of one year from January 2010 to December 2010. Specifically, the clinical presentation, type of foreign body and management outcome were analysed. 72 patients were reviewed - 44 (61.1%) males and 28 (38.9%) females. The age range was one year to 75 years with 59.8% being children below 10 years old. Ear pain (56.9%) was recorded as the most common and persistent symptom and insects (54%) were the commonest foreign body encountered. 95% (69) of the foreign bodies were removed under clinic setting with only three (4.2%) cases requiring general anaesthesia. Post-removal complications were noted in only one patient (1.4%). Repeated attempts by untrained personnel should be avoided and timely referral is vital to avoid undesirable complications.

Study site: torhinolaryngology clinic of Hospital Universiti Sains Malaysia (HUSM)

Matched MeSH terms: Medical Audit
Fulltext An assessment of patient waiting and consultation time in a primary healthcare clinic

Ahmad BA, Khairatul K, Farnaza A

Malays Fam Physician, 2017;12(1):14-21.
PMID: 28503269 MyJurnal

Waiting is a common phenomenon in the doctor's waiting room. The purpose of this audit is to assess patient waiting time and doctor consultation time in a primary healthcare clinic and to formulate strategies for improvement. This audit was conducted at a primary care clinic for 4 weeks using the universal sampling method. All patients who attended the clinic during this period was included in the study except for those who required more time to be seen such as those who were critically ill, aggressive or those who came for repeat medication or procedures only without needing to see the doctor. The time of arrival was captured using the queue management system (QMS) and then the patient was given a timing chit which had to be manually filled by the staff at every station. The waiting time for registration, pre-consultation, consultation, appointment, payment and pharmacy were recorded as well as consultation time. The data were entered into the statistical software SPSS version 17 for analysis. version 17. Results showed that more than half of the patients were registered within 15 minutes (53%) and the average total waiting time from registration to seeing a doctor was 41 minutes. Ninety-nine percentage of patients waited less than 30 minutes to get their medication. The average consultation time was 18.21 minutes. The problems identified in this audit were addressed and strategies formulated to improve the waiting and consultation time were carried out including increasing the number of staff at the registration counter, enforcing the staggered appointment system for follow-up patients and improving the queuing system for walk-in patients.

Matched MeSH terms: Medical Audit
Fulltext An audit of bronchial asthma control at a primary public health care facility

Usha Devi B, Hairul Izwan AR, Munjeet KPS, Rosidah CP

Malaysian Journal of Public Health Medicine, 2011;11(2):22-26.
MyJurnal

A study was conducted at Greentown Health Clinic, Ipoh to assess and classify asthma by levels of control based on the Global Initiative for Asthma (GINA). The secondary objective was to identify those patients whose control was suboptimal. A total of 102 patients were included in this study based on random sampling between 25th April 2008 and 6th June 2008. Standard Asthma Control Questionnaires were used to classify asthma and levels of control. Baseline Peak Expiratory Flow Rate (PEFR) measurements and PEFR at audit visits were also recorded. All data were analysed using SPSS version 13. The study showed that only 39.2 % of the patients were classified as having controlled asthma, 34.3 % had asthma that was partly controlled and 26.5 % of the patients had uncontrolled asthma. Among those patients who had inadequate asthma control, more than half of them had nocturnal attacks and exacerbations. These findings demonstrate the need by the attending doctor to improve assessment of the patient’s control of asthma by actively questioning the patients and subsequently improving management to achieve optimal control of asthma.
Study site: Klinik Kesihatan Greentown, Ipoh, Perak, Malaysia

Matched MeSH terms: Medical Audit*
Fulltext An audit of inpatient case records and suggestions for improvements

Arshad AR, Ganesananthan S, Ajik S

Med J Malaysia, 2000 Sep;55(3):331-40.
PMID: 11200713

A study was carried out in Kuala Lumpur Hospital to review the adequacy of documentation of bio-data and clinical data including clinical examination, progress review, discharge process and doctor's identification in ten of our clinical departments. Twenty criteria were assessed in a retrospective manner to scrutinize the contents of medical notes and subsequently two prospective evaluations were conducted to see improvement in case notes documentation. Deficiencies were revealed in all the criteria selected. However there was a statistically significant improvement in the eleven clinical data criteria in the subsequent two evaluations. Illegibility of case note entries and an excessive usage of abbreviations were noted during this audit. All clinical departments and hospitals should carry out detailed studies into the contents of their medical notes.

Matched MeSH terms: Medical Audit*
Fulltext An audit of intraoperative frozen section in Johor

Khoo JJ

Med J Malaysia, 2004 Mar;59(1):50-5.
PMID: 15535336 MyJurnal

A 4-year-review was carried out on intraoperative frozen section consultations in Sultanah Aminah Hospital, Johor Bahru. Two hundred and fifteen specimens were received from 79 patients in the period between January 1999 and December 2002. An average of 2.72 specimens per patient was received. The overall diagnostic accuracy was high, 97.56%. The diagnoses were deferred in 4.65% of the specimens. False positive diagnoses were made in 3 specimens (1.46%) and false negative diagnoses in 2 specimens (0.98%). This gave an error rate of 2.44%. The main cause of error was incorrect interpretation of the pathologic findings. In the present study, frozen sections showed good sensitivity (97.98%) and specificity (97.16%). Despite its limitations, frozen section is still generally considered to be an accurate mode of intraoperative consultation to assist the surgeon in deciding the best therapeutic approach for his patient at the operating table. The use of frozen section with proper indications was cost-effective as it helped lower the number of reoperations. An audit of intraoperative frozen section from time to time serves as part of an ongoing quality assurance program and should be recommended where the service is available.

Matched MeSH terms: Medical Audit/methods*
Fulltext An audit of parotidectomy in Singapore: a review of 31 cases

Hwang SY, Brett RH

Med J Malaysia, 2003 Jun;58(2):273-8.
PMID: 14569749

A series of 31 consecutive parotidectomies was evaluated. FNAC could differentiate tumour from non tumour in 72.8% of cases. For actual histology, FNAC was correct in 66.6%. Frozen section was correct in differentiating between benign, malignant and inflammatory conditions in all cases. Eighty-eight percent of frozen section histology concurred with final histology. The immediate postoperative period had 13 cases of facial nerve dysfunction, but only 3 cases had residual weakness. The branch most commonly affected was the mandibular branch (92.3%). Two patients had Frey's syndrome and one had a traumatic neuroma. FNAC and CT scans improve preoperative planning, providing histological evidence and the extent of the lesion.

Matched MeSH terms: Medical Audit*
Fulltext An audit of reported acute transfusion reactions in Universiti Kebangsaan Malaysia Medical Centre

Rabeya Y, Abdul-Kahar AH, Leong CF

Malays J Pathol, 2011 Jun;33(1):25-9.
PMID: 21874748 MyJurnal

Transfusion is an irreversible event which carries potential benefits as well as risk to the recipient. The objective of this study was to analyse all reported transfusion reactions of the year 2008 in the Blood Bank Unit of Universiti Kebangsaan Malaysia Medical Centre (UKMMC). This is a retrospective study that was carried out by retrieving data from the laboratory information system. A total of 27842 transfusions were documented and the total reported transfusion reactions were 149. The incidence of transfusion reaction was 1 in 187 of all transfusions (0.54%); in which 69 (0.25%) were allergic in nature and 61 (0.22%) were febrile non-haemolytic transfusion reactions (FNHTR). Hypotensive reactions were identified in 6 (0.02%) patients. There were 9 (0.03%) cases reported with haemoglobinuria where no serological evidence of haemolytic transfusion reaction (HTR) was found. One HTR (0.003%) was identified and this was due to an error in patient identification in the ward. Other specified reactions like transfusion-related acute lung injury (TRALI), bacterial infections, Graft verses host disease (GVHD) were not reported. The highest frequency of the reactions occurred in the red cell transfusions which accounted for 111 cases. In conclusion, the incidences of transfusion reactions are low when compared to those reported by other centres.

Matched MeSH terms: Medical Audit

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