why the doctors are wrong? by Jeannegda catherine Valverde farias, Sr
Malpractice lawsuits
"The worst is not to make a mistake, but try to justify it, rather than use it as providential lightness or notice of our ignorance." Santiago Ramon and Cajal.
The malpractice lawsuits can be seen as a "warnings" that reveal many dark spots or deficiencies in the functioning of both the actions of the doctor, and the institutions and are important to identify faults and malfunctions and correct . In order to determine the causes of errors it is vital that doctors and other health professionals to report them, as this serves to improve and learn from the mistake, that is, there must be the will and the desire to engage in the improvement of the health system. Health professionals must implement the habit which presupposes a fairly significant cultural change, because what matters from the point of view of prevention is to know why, how and where the error occurred? and who can not commit?. (201)
Safety in matters of life is a fundamental principle of patient care, and to improve it requires a series of measures covering all disciplines, both individual and team, of all people working for the welfare of a individual. "Defensive medicine" is nothing but the use of diagnostic and therapeutic procedures in order to avoid malpractice claims and will be responsible for the waste of resources, costs of medicine including liability insurance increase and in turn dehumanize more doctor-patient relationship.(202)
The "therapeutic fierceness" also known as "medical obstinacy" are those medical practices with diagnostic or therapeutic pretensions, that does not really benefit the patient and cause unnecessary suffering, usually in the absence of adequate information in some medical professionals, because no error is tolerated him doctor; however we must remember that not all mistakes made in medicine generate "malpractice". There are also potential risk factors for mistakes such as when concur infrastructure failures where the medical act, among which we can cite methods of insufficient cleaning, flawed in the selection of staff, poor or inadequate sterilization of the material behavior used is exercised and many others, which can cause adverse events, subject to possible future legal claims. The duty of biosafety by the institutions, works with ancillary to the main obligation to provide health care and includes the obligation to monitor and ensure the physical integrity of individuals.(203)
MEDICAL HISTORY. PREVENTION TOOL
In the medical-legal and ethical context, history reaches its maximum dimension in the legal field, because it is the document that reflects not only medical practice but the fulfillment of the main duties of medical personnel, becoming a "documentary evidence" assessing the level of quality of care in cases of medical liability claims and institutions. (204)
Consequently, the history is the medical-legal document which is seated the whole relationship of health personnel to the patient: acts, medical-health activities and is developed in order to facilitate patient care; is a basic element for good health exercise because without it is impossible that the physician has a complete picture of the patient. By that document, studies and research on diseases can be made and performed scientific publications. Is a faithful reflection of the doctor-patient relationship can become a public / semi-public document, the right to access being limited, it can be considered a "certificate of custodial care." It has value of evidence in cases of medical professional liability because it becomes the main material evidence allowing such processes to verify whether it complied with the duty to inform. It is a key instrument of expert opinion, for the manufacture of medico-legal reports regarding medical-professional liability.(205)
The breach or non-performance of a medical history, can boast clinical care malpractice breach of legal regulations, defect management of health services, strengthen risk liability for damage to the patient, institution and administration; as well as medical-legal risk by lack of objective essential element of proof in medical malpractice claims.
The medical history should be secret and intimate, it must contain the identification of the patient as well as the physicians and medical staff who spoke. She must be unique for each patient, orderly, legible, accurate, accurate, complete, contemporaneous to the evaluation of the patient, respectful (no pejorative regarding patient data). Although the ownership history has been highly debated issue because confluence rights and legally protected interests, doctrines on your property are varied: Property doctor, patient property, owned by the institution and integrated theories. Due to current technological advances, computerization of medical records endanger patient some fundamental rights such as privacy and confidentiality. (206)
Preventive strategies in various specialties
SURGERY
All medical specialties are susceptible to mistakes, however, one that is more likely to incur these is surgery, and this is because during it is committed several factors, including also the patient and surgeon other members surgical team, as the anesthesiologist, instrumentalists and circulating nurses, assistant surgeon and the other; are necessary conditions of aseptic and antiseptic, administrative and operational teams to provide a full realization of the surgery. (207)
Unnecessary surgeries
The indication of a surgical procedure to solve a medical problem, is justified only when the disease has a less aggressive solution and will give the patient a better quality of life, better functional ability or deletion of a continuous pain. However, it may happen, that surgical decision is made without conducting a thorough evaluation and without an accurate diagnosis.(208)
Infectious diseases
Nosocomial infections are common during a lengthy hospital stay but not necessarily involving a medical error, they can be prevented if health staff take preventive measures such as hand washing and sterilization equipment. In the United States 80,000 annual deaths are attributed to nosocomial infections, 12,000 deaths from unnecessary surgeries and 7,000 deaths caused by inappropriate medication errors in hospitals.(209)
Anesthesia
Any allowable error within other medical specialties can become a catastrophe in the area of anesthesiology. Often the most common medical faults in anesthesiology include mistakes in the dose of anesthetic administered, can happen when a given drug is wrongly labeled, resulting in the administration of an incorrect dose, the wrong can occur both when administered in very small quantity or overdose. Among the causes of errors are also the delay in the post-anesthetic recovery, failure or damage caused during intubation, and inadequate monitoring of the patient. The anesthesiologist is responsible for monitoring the level of consciousness during the procedure, and should not leave the bedside as this, deserves constant attention. Situations such as turning off the alarm pulse oximeter, to an inappropriate oxygen during surgery, the anesthesiologist is under the influence of drugs or alcohol in the process, using faulty equipment or apply a dangerously prolonged sedation can lead to situations extremely dangerous for the patient's life. (210)
As preventive measures, should be labeled each drug carefully, placing legibly, the information content of each syringe or vial organizing drugs, and their position and separation in the closet or dresser, having to organize the potentially dangerous drugs used in the operating room, and the labels of these medications should be reviewed with the help of a second person, in order to prevent an error during the administration of a product. In the case of a mistake in the administration of a drug occurs, it must be reported in a book intended for such eventualities. The inventory and check the expiration date of medicines, are also useful to avoid mistakes; and, provide a bar code, ID Color of each drug and its generic name. It should be emphasized that the use of surveillance protocols, and careful thought before the decision or medical act are key to avoid committing mistakes.(211)
The consequences that could result from errors of anesthesia include tracheal damage, suffocation by inadequate oxygen, heart damage that may include myocardial in
Transfusional Medicine
In transfusion medicine has reached consensus that the following measures by errors could be avoided in transfusions:
• Having a good system of patient identification, including labels and barcode.
• To combat misinformation of personnel working in the area of blood bank and medical personnel so that through a "feedback" or working together better health work can be performed.
• Using pre-printed labels and automation optimizes time and avoid errors in patient identification
• Hospital Transfusion Committee is in charge of haemovigilance, monitoring of patients at high risk or who polytransfused there was an incident. It has a close relationship with the hospital medical team through meetings
• Have a computer network allows fast in terms of services, information and links to other health centers.
• To request voluntary consent before a transfusion reported.
• Comply with the rules laid down in the rules of Blood Bank.
• Understand and be aware of the possible consequences or adverse effects of transfusion.
• Respect the time established between several transfusions of blood products in the same individual.
SUGGESTIONS TO PREVENT MEDICAL MALPRACTICE
• Never lie.
Writing in the medical history all the facts as they happened. Explain the same way, without altering the truth to the patient and family what happened.
• Be cautious.
Caution should be one of the bastions to realize good medical practice. Given the uncertainty about the danger of a test or medication, discuss with a colleague who has more experience, knowledge or hierarchy, likewise, case discussions and anatomical and clinical meetings are highly valued.
• Acquire expertise and skill.
The physician should be learned in the realization of differential diagnoses and invasive procedures (if your medical specialty so requires); if you are uncomfortable or doubt diagnosis, treatment or behavior, you must precede the benefit of the patient to his own ego and consult colleagues who have proven track record in what is unknown or no experience.
• Having a diligent, responsible, prudent and assertive attitude with patients and colleagues. So communication is important, as the discussion of the cases with the team.
• Stating constancy.
A complete medical history and record the proceedings. Report all relevant data of signs and symptoms, laboratory tests, imaging, biopsies and consultations, among others. All this will allow the organization of the useful elements for engaging definitive diagnosis and treatment of patients.
• Recognize the limits and capabilities. This means that the doctor should abandon their pride and admit when they should not or can not meet the requirement of a patient.
• Raising the quality of health services
• Implementation of bioethics committees in clinics and hospitals to discuss problems of medical malpractice and errors and to design preventive strategies according to the strengths and weaknesses of the health institution.
• Inform patients about the characteristics of the medical act.
• Encourage and be friendly and respectful relationship with the patient and family.
• Attitude to an error or unforeseen situation. It must be admitted as soon happen, report, communicate with the head immediately above, take corrective or preventive actions of the case to avoid potential consequences; prevent concealment, forgery, falsification of data or missing documents. After an unwanted result, it should be given as soon as possible a serious and responsible explanation to the patient and their families on the causes or factors that determined and the measures to be taken to reverse or correct it.
• Do not overestimate techniques or new instruments. Remember that nothing replaces a good history or medical history and a thorough examination by physical examination in order to arrive at a diagnosis.
• The patient must be educated and documented. Except in emergencies, that endanger their lives or the arrival at a health center with impaired level of consciousness or vital signs must come before or consult a physician, ask for references and information about your moral and ethical soundness, as well as the latter's competence in the area or discipline which claims to be trained.
• Except in cases of real emergencies, health personnel should not practice in inadequate or unfit to practice medicine conditions.
• The doctor must not diagnose, prescribe, diagnose, treatments indicate electronically (telephone and computer), remote or through third parties.
• Avoid defensive medicine
• Refuse to engage in unhealthy or defamatory comments between colleagues, especially in the presence of patients and third parties.
• know and faithfully comply with the guidelines, codes, existing regulations.
• Safeguard medical records to prevent loss, theft leaves, corrections, and other situations that diminish their value as evidence.
• Require the provision necessary in order to make a good medical practice and report unsafe situations both in health care facilities; as insecurity of all staff to better delivery of health services.
• Never leave the patient.
• Safeguard confidentiality.
PATIENT an active role in the prevention of medical mistakes
The patient must be involved, informed and know their rights, consider choosing a hospital that has experience in your condition or illness, request information from the procedure performed and their potential complications, risks, consequences, the existence of alternative therapies and choice of doctor. (212)
At discharge, the patient must request instructions, treatment, written instructions and recommendations to follow at home. You must know your treating physician and delegate to a relative, guardian or person to be your "attorney" in case you can not make decisions for yourself, or if you risk losing your state of consciousness or enters state coma.(213)
The general population does not readily accept that, regardless of the severity of the process or the interest and resources spent, not a satisfactory result and in this case, some people born in the desire to repair the damage at least economically. For its part, the relationship between behavior and health standards usual standards for a specific case, assumes the existence of protocols, clinical guidelines or specific sanitary standards that can justify and protect the medical procedure to be followed. These standards will have more recognition if they are covered by a national, regional or at least by a hospital committee scientific society.
Medical errors unfortunately, lead to a loss of confidence in the health system and high costs to the state. In addition, patients with long hospital stay or who have suffered injury or disability as a result of a medical error, often have psychological disorders. Health professionals also can present frustration and loss of morale when they make a mistake. Among the suggested strategies proposed to establish medical protocols, tools, leadership and knowledge based security systems. It should identify and learn from mistakes, promote development organizations strategies and preventive measures. Discussions about medical errors, facilitate professional learning for physicians and provide emotional support after such events, they may be vented in anatomoclinical meetings, however, little has been investigated. (214)
Kaladjian, surveyed teachers and residents of several hospitals located in areas of the Midwest and northeastern United States, to investigate the attitudes and practices regarding discussions of errors, mistakes hypothetical, experience modeling roles error, demographic variables, and found that 338 doctors agreed to participate only 73% indicating they used to talk abou
There are some doctors who tend to think that many patients have psychological, or even have hypochondriacal traits disorders, and surprisingly some hospitals in North America have reached will implement a system of triage care consultations by colorimetry with expectations to combat this phenomenon; colors are used to classify patients according to the severity of their disease and taking into account the reason for your inquiry, after evaluating it is assigned a "timeout"; however, patients should be educated and learn about the cardinal or more frequent symptom in a serious condition. Some patients who have gone to emergency rooms have been categorized as "chronic offenders" one who is "unhappy and looking for a second or third opinion", "internet", the one who "feels alone and just want to search company chat "," aggressive "or agitator," empathetic "apologizing for coming so, among others.
The philanthropic image of medical professionals, has been deteriorating and distancing in the last 50 years of the Hippocratic model for millennia equated; to be considered as a single technical, eager for economic recognition and professional, closely adhering to a scientific model, isolated in some cases of human sensitivity consubstantial with the practice of conventional medicine, the medical humanism sustained for posterity the most qualified ecumenical cultists, such as Hippocrates, Aristotle, Plato who provided essential concepts to define spirituality thought.
Today, the practice of modern medicine, suffering from a process of dehumanization in the globalized society, especially in developed societies with modern, materialistic, hedonistic life with empty values and cult of banality, in which context, health has been turned into an expensive commodity for a perverse market; which it has made its leitmotiv profit greed. (215)
Moreover, most doctors have uncritically identified with the technology, essentially leaving the detriment of their professional identity, focused on projecting a higher socioeconomic status and personal gain, lacking social sensitivity to image classes neediest.
Similarly, companies in the third world suffer from this medical desensitization process to the detriment of disadvantaged social factors with access to health services often inaccessible; however, not less certain, the overwhelming rhetoric to the contrary, argues that political, social, economic and labor changes have been accompanied in recent decades of low wages for doctors and that their work is developed in squalid conditions, they make it unfeasible quality care and creates conditions for involuntary medical errors. (216)
Dr. Fabian Vitolo, in a paper presented at the 1st "National Meeting of Leaders of Health" occurred in the Noa-Termas de Rio Hondo region in June 2007 on "Civil liability and medical malpractice" found differences in the physician specialty and responsibility. Obstetricians occupied 26%, followed by 25% surgeons, chiropractors 14%, pediatricians 10% , clinical physicians (internists) 9%, infectious disease 8% , anesthesiologists 4% and plastic surgery 4% . However, the study Vitolo agrees with that conducted in Mexico during the period 1996 - 2007 at the National Center for Epidemiological Surveillance and Disease Control in Mexico, where obstetrics and gynecology received 15% of the complaints or demands, orthopedics and traumatology 12 , 5%, medical emergencies 10%, 7.3% general surgery, dentistry 7%, 6.3% family medicine and internal medicine received only 2.4%.
Medical error is a central issue in the world. An Institute of Medicine in Washington says the incompetence, negligence, breach of rules and regulations, is only a small part of the problem, and emphasizes the importance of the environment and the system in which medical practice develops. Medical errors occur generally good professionals, trying to make things better and are simple errors. (217)
According to a study in the US for over 15 years it showed that less than 2% of the damage caused by negligence, was compensated. Means that medical action can be the inexperience, the professional has little chance of being sued, just as there are many demands that have no technical basis.
In a study conducted by Campos in 2008, he found, through an anonymous survey of medical professionals, they said that in a universe of 1000-1500 surgeries, 30% admitted having been forgotten a compress on the abdominal cavity during surgery and 90% learned that a colleague had. It is claimed that the true incidence of this event is underreported, it is estimated to occur in 1: 8800 general surgeries and 1: 1000-1500 abdominal surgery; while in the US 1500 cases are reported annually. Among the types of foreign bodies 69% corresponded to packs of different sizes and clamps 31%, cavities described as "retention sites" 54% abdominal, vaginal 16-22%, thorax 7.4%, elsewhere as face, brain, extremities 17%. The time between surgery and retained foreign body detecting this, time ranged from 1 day to 6 years. (218)
Thus, as the Royal Spanish Language Academy (REA) defines as "oblito" (from the Latin “oblitum” forgotten) foreign body forgotten inside a patient during surgery. A study published by Manrique and collaborators in Argentina, shows a casuistry with an incidence of 2.4 / 1,000 surgical operations performed. This research included among the risk factors to cause forgetfulness, emergency surgeries, unexpected changes in the surgical plan, inability to account for extreme urgency with each other (which can lead to a wrong count) "stuck" gauze; also multiple teams, excessive bleeding, change in personnel during surgery, tiredness or fatigue of the surgical team for long, multiple and complex procedures during the same surgical procedure surgeries. (219)
There is case law on the issue of neglect of a foreign body. Among the legal doctrines applied are "Res Ipsa Loquitur," which means "things speak for themselves," the foreign body is forgotten as a result of a negligent act and one is "captain of the ship", for example the surgeon is ultimately responsible and that is who placed the missed pad, the latter principle, each real day less applied and because the whole team has some degree of responsibility. Everything has been forced to develop rules and procedures count gauze (pads) and surgical instruments. So it is recommended that:
Gauze compresses should not be cut and should be counted at the beginning and completion of all surgery.
The number and type of needles must match the suture packages used (open).
• The surgical instruments used must be recorded at the beginning and end of surgery. Caution should be exercised with the break or separation of any part of the instruments (self- retaining tabs, laparoscopic forceps, needle Veress).
When and how to count ?
• Before starting the surgical procedure to establish a baseline and at the end.
• Before closing the cavity and the start of skin closure.
• Before relief staff, I need to continue the surgery. These are the most common reasons why forgetfulness happen.
• The counts should be performed audibly under the vision of two people.
If the count is dissenting must document and report to the surgeon. Suspend the procedure if the patient's condition permitting, inspecting the surroundings, perform radiological monitoring and report the incident to the responsible operating room.
The shortcomings reported by physicians in this study, in relation to the provision of diagnostics, such as imaging (MRI), intensive care units both adult and child (ICU, PICU, NICU), oxygen, incubators, ambulances, lack resources occupational safety, poor auxiliary power plants, water, blood banks and sufficient drugs were reported by 79% of physicians surveyed as failures provision in their hospitals, since they are necessary to ensure quality care and reach accurate diagnosis and treatment, so that a good part of medical malpractice and errors
On several occasions, the hospitals have the equipment, however, for lack of maintenance become damaged . In conversation with the doctors, they reported that the failures of elevators in good condition, aggravates the situation of trauma patients, who are forced to climb stairs anyway and as they can, looking for other services to complement its attention . Likewise, they referred to the serious situation faced by cancer patients by not having chemotherapy and radiotherapy in a timely manner. The HIV-AIDS sufferers, have suspended at the time of this study treatment due to lack of existence. But simple things like having blood bank to place a blood to a wounded, a septic newborn, or ambulance to transport a patient to warrant Intensive Care Unit, a specialized examination or plain radiography to be photographed with cell for interpretation so as to derive a laboring woman in labor to another center where there is surgery available (anesthesiologist), are common situations mentioned by respondents doctors. (220)
Another situation concerning and worrying is the ongoing insecurity that doctors live as a result of the underworld, in and around their workplaces because they are frequent victims of robberies, injuries and even deaths. This situation does not escape other cities of Venezuela, Carabobo State, the finance secretary of the College of Physicians, Dr. Jose Antonio Guevara, reported that public health centers in that state you were just 5% in sutures and other syringes resources by June 2014. The Venezuelan Association of Distributors of Medical-Dental and related equipment (AVEDEM), reported on May 26, 2014, that peripheral and coronary stents, which are cylindrical cannulas in endoluminal use (usually endovascular) which is placed inside of an anatomical structure or body duct to keep permeable and prevent their collapse after dilatation, and unblocking or surgical release allowing dilate the arteries and vessels to restore proper blood flow, used in heart disease, carotid and lower limbs are faulted in the Public Health Centers (large hospitals) and private clinics. Most alarming of this information are the consequences resulting from it, since placing this kind of prosthesis prevents the patient from cardiac death, or keep a patient with impaired circulation return legs to be amputated.
In other latitudes like Spain in 2011 killed 603 people for alleged medical malpractice and in 2012 did 692 which shows an increase of 89 cases per year. Generally these deaths occurred by surgical procedures performed poorly, poor clinical care that the patient had, nosocomial infections, delays in the arrival of the ambulance; but the main reason was due to misdiagnosis and missed opportunity to implement an early and successful therapy. (221)
Our study was conducted in public hospitals with doctors providing their services in these centers, however 41% complemented their time and wage work in private clinics or private practice were, allowing inquire about the incidence of errors and failed to confirm the rule that also in private health centers, oversights occur during surgery, anesthetic errors, confusion stories and examination of a patient with another mistake when placing drugs. This situation has allowed the patient now receives information on the medicine and treatment that is being given (Informed Consent). It is important to comment that working hours of medical residents, graduate students and even specialists, exquisitely strenuous occur guards for these professionals, because low wages are forced to work in more than one site and redoubled their hours job. More than 53% of the survey group, performing continuous guards just over 24 hours, or patients with excess charge, was the common denominator of the group. (222)
There are medical work schedules perverse and even criminal in the practice of medicine, the United States is the industrialized country with the most demanding working hours. This practice has the additional problem that its consequences are more related to labor accidents caused by the amount of hours activity without rest, for the type of work performed. Fatigue and stress accumulated during the day too, affects the health of people and the conditions to have more traffic accidents and other as well as to make more medical errors. What is unusual is that this situation is neglected in the medicine itself, as US medical residents work up to 30 continuous hours. (223)
A publication by Reuters Health, reported that long sessions of work of doctors in training in US hospitals are creating an alarming number of medical mistakes, closely related fatigue, and usually cause death of patients , according to research. When practicing physicians practicing in shifts ranging between 24 and 30 hours, the risk of committing serious mistakes that can affect patients shooting, revealed experts at Brigham and Women's Hospital in Boston.(224)
Doctors evaluated in relation to this, were practitioners who were 4.1 times more likely to commit medical errors related to fatigue and that killed the patient after working five or more days per month extended compared to a month without work shifts as long as indicated. This form of work by the medical team, dating back to the 1890s in US hospitals, forcing medical residents to work extremely long shifts. Proponents of this practice, which is considered vital for a new medical personally follow patients throughout their hospital stay, partly to learn about the course of various diseases. The study results were based on a survey of 2,737 physicians from various medical specialties American hospitals.
"We found that for every 100 practitioners who worked one year, committed on average 200 major medical errors, 20 which caused an avoidable injury and five serious mistakes that caused preventable deaths in their patients," the doctor who directed said in a telephone interview study.
If these results are applied to the 100,000 young doctors who work with these schedules in hospitals in the United States, means that there are about 100,000 significant medical mistakes, tens of thousands of preventable injuries to patients and thousands of deaths each year could you prevent fatigue related.(225)
The Service Employees International Union, the largest union that brings together medical practitioners and residents of US hospitals, said the results of this study caused more fear because medical centers allowed those new doctors work between 24 and 30 hours , two to three times per week. The union reiterated their call for the US Congress legislation imposing limits on working hours for residents.
In Spain, a survey conducted in 2005 by the Spanish Association of Resident Physicians (AEMIR), showed that more than half of the resident not waged, for example, there was free after a guard, which reached perform 32 days of almost continuous hours without rest. 18% admitted using drugs in a systematic way to prevent sleep, an overwhelming 60% of physicians surveyed, reported having committed a grave error in the exercise of their profession because of fatigue and 35% claimed to have suffered accidents transit after finishing the guard and in conclusion the long working hours are not only unhealthy for workers, but can be dangerous for third parties.(226)
In this regard, it is appropriate to insist on a day unfavorable excessively long guard, the willingness to make mistakes. In a degree thesis in the specialty of psychiatry at the University of Los Andes in Venezuela (ULA), studying survey of 215 physicians, 60% were women, of which 66% had mild symptoms of burnout syndrome. 142 physicians showed mild symptoms, 7 moderate symptoms were evaluated postgraduate pediatrics, internal medicine, traumatology and orthopedics, and cardiology, concluding that errors are more likely to be committed if the uninterrupted work sessions take several hours. (227)
A resident physician concerned with the "burnout syndrome" has a greater tendency to commit medical errors that cause high costs for the patient's health and contribute to aggravate
In the United States, the Commission on Accreditation of Healthcare Organizations (JCAHO) in 2001 recommended that in the hospitals associated with it, are established policies for the welfare of its staff. Many times, the attitude assumed by the doctor against patient is crucial to secure a good doctor-patient relationship and thus mitigate, correct and to avoid an error. It would be interesting that the strategies adopted by other countries could be applied in Venezuela where working hours are extremely strenuous especially for young doctors.(228)
From the outset it should warn the patient about the risks comprising all medical procedures under the unpredictable variables imperfect science as it is. However, the medical practice has its rules of conduct and one of them is the "professional responsibility", which come to be a systematic set of rules that guide and indict the practice of medicine within the principles of its own, that is, as well as respect for human dignity and right to life and integrity, including respect for fundamental rights such as the right to identity, freedom of conscience, health, personal and family privacy, ethnicity, cultural and the right to social Security. In the doctor-patient relationship, the doctor must ensure these principles and rights, and to prioritize their decisions based on the best interest of the patient, without differentiation or discrimination, serving them with respect and dedication, in any case, the violation these moral and professional principles will constitute what is called professional ethics responsibility, adapting their behavior to a wrongful act that medical professionals could avoid. (229)
For purely educational purposes, to be put at stake the apparatus of responsibility is necessary to have medical misconduct or breach of professional duties, and that the liability be configured, pre-existing following requirements Obligation must occur, lack medical (incompetence, recklessness, negligence, breach of duties and regulations in charge), the damage, causal determinism between the medical act and the damage and accountability (for example, had the doctor is guilty of having caused the damage). (185)
Other causes listed in the jurisprudence consulted to decide this case concerned:
1. Guilt
2. Damage
3. The link (causal determinism):
This law is explicit when it states that:
• When there is damage, without any fault, we can not speak of medical malpractice.
• When there is a lack, without any damage, you can not talk about medical malpractice.
• When missing and damage are present, with no causal determinism between them, can not talk about medical malpractice.
To be configured malpractice from the legal standpoint, it is imperative that three elements simultaneously concur:
• There is evidence of a medical failure
• There is evidence of harm to the patient
• There is evidence of a causal link between the fault and the damage caused to the patient.
CONCLUSIONS
Medical mistakes are sometimes supervening situations frequently in medical practice and sometimes are related to misinformation or judgment regarding a particular disease or condition. The extent of this problem in Venezuela is not well understood. According to statistics in the first world countries, there is high morbidity and mortality because of it.
There are a multitude of environmental factors that conspire around the crystallization of a medical error or adverse event as poor professional information, little training in modern techniques, lack of innovation in equipment and structures. If we add poor working conditions, with failures in the provision of diagnostic and therapeutic tools, the result can be fatal.
It must be remembered that within the ethical training of medical professional is the "do no harm" known as "First Do No Harm" and it is important to reflect on it, because the doctor does not act with malice in their quest to cure. When allegations of medical malpractice occur, they must coexist many variables that demonstrate the professional attitude was not due to violation of the lex artis, manuals of procedures or standards; and that in any case he worked with some element of guilt.
Moreover, the practice of medicine has never been easy, the proof is the long years of study, unlike other professions, medicine not computers are managed, not a repair shop or a bank, neither is mathematics. Each patient has a pace of improvement or deterioration and response to specific treatment according to their characteristics single, genetics, immune system, allergy history, access to health care or psychological predisposition.
Before starting a titanic litigation under the assumption that there has been medical malpractice, the patient or family should seek advice and well informed about the details of what happened, talk to the doctor, and even try to reach a settlement as this brings benefits in that it is a more expeditious way to obtain financial reparation lawsuits and avoid long waits. In addition, the doctor will be emphasized, which has been shown that many claims could be avoided if there were a frank and open communication with the patient about the disease, treatment to follow behavior, the risk / benefit or adverse effects that may occur and protect at all times the doctor / patient relationship. Communication should be used as a highly effective tool in the health team, because if it is poor or failed; you can lead not only to medical errors, it creates a dangerous situation that increases the risk of injury to the patient.
In this sense, the medical history is valuable as evidence of the narrative of events and the sequence in the evolution of the disease. A "bad history", is one full of inaccuracies and lack of data leading to misdiagnosis and resulting in poor treatment, while a well-worn story exonerates blame the doctor and releases of liability in an unfair trial. At the same time, you are at risk as any other person or professional, incurred through the exercise of the medical act on failures by act or omission, which in turn do creditor of civil, administrative and criminal liabilities. Responsibility within the practice is well demarcated and restricted legally, under the special training and exercise his transcendent mission, nobility, dignity and ethics of the work performed, the most sacred possessions of the human person is linked , this is life and health, personal rights that constitute the essence of the human individual and social.
Medicine, the same as the free exercise of any profession, art or industry finds its legal and categorical basis in the Constitution of the Bolivarian Republic of Venezuela provides in Chapter V, referred to social rights and families quote: "Work is a social right and enjoy state protection. The law provides for improving the material, moral and intellectual conditions of workers. To fulfill this obligation, the State established the following principles”:
• No law shall establish provisions that alter the sanctity and progressiveness of the rights and benefits. In labor relations, reality shall prevail over forms or appearances.
• Labor rights are inalienable. All action is void, arrangement or agreement waiving or impairment of these rights. It is only possible and settlements at the end of the employment relationship, in accordance with the requirements established by law ". End quote. Moreover the C.R.B.V. Article 105 states: "The law shall determine the professions that require degree and the conditions that must be met to practice including licensing" unquote. In general, these provisions regulate to some extent the practice of medicine, which undoubtedly meets a job or social work and requires the compulsory licensing of its members. For his part, Venezuelan Civil Code (continuing the legal standard) defines the nature of the doctor-patient relationship as a source of contractual obligations; but establishing an obligation of means and not ends. (118) The legal framework in the strict sense of the Law Practice of Medicine, defines and regulates the exercise of the medical profession in several articles of the body of rules. Professional liability is a particular focus of the overall responsibility, analyzed from the angle of t
In recent times and for various reasons, the mistakes made in medicine are a forbidden subject for doctors, where some exceptions, the messages are contradictory, usually psychological mechanisms not fully say what you think, abound self-defense and things are not called by name, in an effort to hide realities. Learning from past mistakes instead of hiding leaves a very useful experience as we have been saying since become a tool where it actively engages the patient, his family and the general population as key and important pieces of preventive strategy.
Claim the complete elimination of medical failures is an intangible goal. In principle there must be motivation and desire to improve, a good option is to start with the recommendation in Venezuela of creating a systematic record of mistakes, where more than endeavor to identify who was to blame, it is more beneficial to know the precipitating causes of such events. For example, an error such as mistaking the route of administration of a substance can kill a patient, hence the importance of monitoring and constructive criticism to avoid irreparable damage.
In industrialized countries, about 9% of patients admitted to hospitals in Canada, France, United Kingdom and Denmark in 2006 suffered an adverse event related to health care so that every physician confirms that exercise is subject to the risk of to make mistakes. (35)
Communicate hospital policy mistakes helps improve many aspects, among which stand out:
• Dilute the traditional error concealment.
• Create programs and strategies to prevent and use more secure systems.
• Forces medical personnel to take an honest attitude, according to their ethics, as it is shown that communicate or report a mistake when he suffered patient or their families, it is one of the aspects that generate greater difficulty but avoid legal conflicts.
It is necessary that medical professionals understand that increasing their mistakes increases the malpractice and although the company refuses to accept it, we must keep in mind the role they play in this field insurers, whose work and economic interest is to ensure against risks and accidents.
Meanwhile, the hospital administration needs to resolve in the best way the crisis management in order to optimize the quality of the provision of health services. Is a constant that the biggest obstacle that exists in improving health services is the existing hostility in communication between workers. In some situations, hospital directors, heads of services, heads of teams and in general those who hold positions of leadership functions, assume behaviors that can be classified as verbal abuse, with the junior workers, as a way of managing power, and this is a style of communication unprofessional and unfortunately common, showing aggression caused by power being imposed boss or the professional status they have.
Clearly, the hostile environment, causes backfire by creating resentment among members of the health community, due to demoralization and demotivation among them. Discuss verbal hostility in hospitals remains a judice and helps employees feel afraid to report a system failure when it happens and thus; from finding solutions for the benefit of the patient or the health system. Despite this, it is believed that the Occupational Health could help prevent such abuses.
Building good relations among workers of a hospital, always give effective results to handle disagreements between service personnel, departments and coordinators, as emotional stress is reduced, fears and fears are overcome and creates both a atmosphere of peace and harmony, making it a fun atmosphere is important in order to reduce work stress.
The death of a patient as a result of mistake or malpractice, creates a psychological trauma for doctor, sometimes warrant professional help. There is insufficient information in Venezuela, on the effects or consequences of malpractice carries on workers health system. Only it knows that in some hospitals are removed from office in unfairly opportunities; while it is true that many of them are victims of transporting that "spiral" of ignorance, which leads them to fail. Thus it emerges as a necessity, rescue and dignify with education, the true image of the doctor in our society.
RECOMMENDATIONS
The great power of modern medicine and its healing progress should go hand in hand with a great philanthropic and humanist sentiment. Ironically in recent years in the US, despite being more technology and knowledge development they have not diminished error rates and the costs of these. It seems survive a feeling in patients that the health system is a completely sealed "black box", hidden and unknown secrets, unfortunately both doctors and health institutions shirk their responsibility and the lack of transparency and lack of reports about medical errors or adverse events resulting system not report the defects or weaknesses that require controlled or corrected. It is imperative today informed and educated in health so that their decisions are sound, but on the other hand, health care is accountable equally and reward good work performance with monetary remuneration patient and in turn motivating the work team, encouraging testing and care in all steps concerning the process of healing the sick.
Medical mistakes are the fifth leading cause of death according to statistics in North America, but the problem becomes even more complex when you know there are many good doctors working in poor hospitals and while politicians argue long hours on financing health, ignore as repair or make corrections in a health system that is already damaged.
Exist a poor tolerance by the doctor to reveal the truth, but you need to always be honest with the patient; some health facilities are less "safe" than we think. Some errors that occur in health sometimes occur in patients who did not want or need certain medical procedures; in fact, one of every 5 tests, medications or procedures are determined to be unnecessary and probably unfortunately this is also true for hospitals and clinics that are in great respect and prestige where even detected the production of medical complications 4-5 times more than other lower category.
Accidents and hospital statistics about error and malpractice are hidden from public view, people do not have access to them as patients or taxpayers. US people pay a certain amount of money for the proper functioning of the health system; there is no way to measure or find out if their treatment is good, adequate or at least safe. That is why the citizens must require disclosure of statistics patient care: errors and malpractice procedures a hospital, it would be comparable to buying a vehicle where the buyer is entitled to know the safety record one to make the decision to buy or not; similarly, the consumer health care is entitled to know the quality of care that will be provided. Ideally if a patient is considering a possible surgery should be open access to health care information in different centers on rates of complications and deaths in the process is to be applied. In the United States there is an institution called "National Bank data collected by the Department of Health and Human Services" and is popularly known under the name of national "black list" of doctors; surprisingly when a physician requests the list is handed a version with the names of the doctors cleared and who may only have access to those names are state medical boards or the Department of Human Resources are responsible for doing the background check.
All those who work in the health area known medical mistakes but nobody talks about this issue. The health administration, paramedics, auxiliary and nursing often discussed medical mistakes as a powerful warning to the medical community to keep it "outside", know the mortality rates, c
We must consider that although it is true that almost all medical diagnoses are obtained thanks to the data provided by the patient's medical history, there are many doctors who dismiss the great value of this instrument. Factors such as algorithms or protocols of action, fear of making mistakes and technology have relegated the medical interview to the call stack data on a sheet of questions. In the US there has been an abuse of the use of scanners and imaging in general of resources; said that "we are losing the art of medicine" and it seems that the media does not have a priority to listen to patients, consequently all this entails more costs for the State which translates to an increase in tax collection and impoverishment of the user.
In order to reduce the frequency of medical mistakes, we have been proposed ideas that can contribute to their decline, however, one of the great enemies of patient safety is the lack of communication between team members and health failure to notify any "failure" in the line of execution of a process. The medicine practiced today, given the technological and scientific advances is much more complex than 50 years ago, while new diseases have emerged, including work-related. While it is certainly much more effective therapeutics, also it means greater risks for the use of installations and equipment for special procedures.
According wide range of experts, mistakes are inevitable in healthcare, and even if despite all efforts the risk remains always a mistake, the following recommendations are suggested:
1. The performance of the medical profession should be given with care and dignity, ensuring the utmost respect for the lives of the sick and never use scientific knowledge gained during studies of medical career to repeal the laws. The "Ethos" is a distinctive doctor attitude, which characterizes it as a professional vocation irrevocable community service and a dedication to "values" rather than financial gain. The health team personnel must be trained and trained frequently to stay updated on new diseases, techniques and protocols. Discussion of clinical cases, symposiums and any activity that promotes or reinforces the medical training must be respected and enforced codes of conduct and help up the anatomical and clinical meetings. Always consider the differential diagnosis in each disease; and in turn the patient should seek the reasons for each medical examination and it must be able to explain what the test is looking for treatment will be aimed depending on the diagnosis.
2. The ethical behavior, it is an honest self-imposed duty, jealous and proud not to yield to certain temptations doctor. Unethical practices could submit it to the disapproval of other colleagues with a moral sanction, which involve greater punishment than legal sanction and is detached from it.
Strict compliance with medical principles, trying to others, that which, in similar circumstances would wish for yourself and for your loved ones.
3. The medical records are documents that must be prepared under the responsibility of a doctor, who will take care to apply the knowledge and resources available in order that a clinical case study demonstrates the respective disease at any time. Your prescription should be clear, legible, accurate, concise, chronological, truthful, no unrecognized and abbreviations listed. It is a contravention of medical ethics, the entries in the stories, derogatory comments or offensive to the patient. Medical records should be guarded, must not contain breaks, amendments or absence of their pages. It is reprehensible, the inclusion of false data, blots, adulterations, substitutions or removal of leaves, by not agree on what was described or for the purpose of concealing mistakes. It is estimated that failure data must register with a medical history, constitute an obstacle to the applicant in its attempt to prove malpractice. This fault is considered by itself, as additional damage to be compensated.
The physician in private practice as equally public and hospital authorities must take all possible precautions to preserve the confidentiality of information provided by the patient, in terms of confidentiality. The confidential document and the necessary preservation of medical confidentiality, forces his cautious and discreet use, so that the property is respected and not something that should be kept in reserve disclosure. Should judicial inquiries for lawsuits against a doctor, a medical history must be used, for they were filed, only that part of it that is relevant to the trial, ensuring that the rest of the information is excluded and held by the institution.
4. The doctor-patient relationship has theoretical and practical importance because it is essential for the correct interpretation of the causes and mechanisms of disease production. It is an element of methodological guidance to improve the health and helps to clarify the close link between soma and psyche. It follows that there is a fundamental pillar, the doctor is obliged to use as a first step before the sick. People is talking about of "empowerment" of the patient, where it must demand to be heard without interruption, have the necessary information and know their rights, make their own questions, to see if the medical points in history that the patient is paramount in his sickness.
Universally it considered that doctors do not have the reputation of being the best listeners, and communication in basic for a good diagnosis and factors affecting it are manifold from a lack of empathy, the pressure of time given to each patient and doctors may be distracted by technological devices. Painfully has determined that in the US the white doctors tend to talk more and listen less to black patients, the money often can be included in medical decisions. Doctors very often do not listen to patients and undergo excessive testing and then to overtreatment. When a patient pronounces the words "chest pain" the doctors can put an immediate plan of action giving patients aspirin, performing an electrocardiogram to evaluate cardiac activity, taking blood tests to measure cardiac enzymes, x-rays and very possibly keep the inpatient for 12-24 hours in order to rule out or confirm a heart attack but the patient does not have pathognomonic symptoms because the doctors make use of standard protocols in their evaluations and have lost the so-called "art of listening "; it looks like a failure in the training of doctors don´t use reasoning and deductive process and relegated to technology analysis and blood and imaging diagnosis.
5. Recent years have shown that patient autonomy is not a panacea for all the problems of the doctor-patient relationship and the extreme autonomist leads to contradictions such as insufferable paternalism of the physician himself. Faced with this paradox, the physician must provide a pure charity, excent of any kind of paternalism and the patient must abandon its previous attitude obedicence blind and bring into play the resources of their autonomy. Medical attention should begin verbally on what should be done, hence the importance of informed consent, so that the same, is the new face of the doctor-patient relationship for the benefit of an optimal result.
The doctor should involve your patient in making decisions aimed at achieving restore your health, taking into account respect for the autonomy of his will as a right. Establish a contractual relationship where the patient also "informed consent", he accepts the conditions, risks and chances of success of the medical act, ideal in written form, it can not be obtained through a simple signature or a hurried reading of tiny text
6. The physician must obtain sufficient patient medical history information about the types of drug products that are receiving, their addiction to coffee, snuff, psychotropic substances, alcohol, drugs, allergies, drug interactions and adverse reactions that occur certain types of drugs or substances.
7. The indications, also known as “Medical Recipes” should be written clearly and legibly, so that before the patient leaves the doctor's office should explain in detail how to take the treatment, time use, adverse or side effects of medication. When a prescription (doctor recipe) make sure you can read it and understand it, the patient should not remain silent and give you analysis and procedures should be explained. It should also require your address with phone and simultaneously supply their own so that in case of any eventuality they can communicate. It should encourage the patient is an active participant in every decision, informing the doctor without reservations of the conditions, treatment, addiction and others consider relevant.
8. The physician is ethically and legally bound to secrecy of all that come to its knowledge by reason or occasion for its exercise. Medical secrecy belongs to the practice of medicine and is imposed to protect the patient safeguarding the honor of the doctor, it is inviolable and doctors are obliged not to divulge it.
9. Create useful tools to prevent medical error to lead to malpractice such as:
A. Avoid a positive environment and not fall into the game of "find a culprit."
B. Review the error internally and make an interdisciplinary analysis of incidents that resulted and an analysis of their root cause.
C. Develop honest discussions on issues of biosecurity, hygiene, environmental safety and options on all levels of the organization.
D. The physician should be familiar with the medical history and current status of treatment it receives, before starting to treat it. You must communicate and educate paramedics, patients and their families about the disease or condition in order to ensure the success of treatment and healing.
10. With regard to documentation and registration: We must establish registration systems for reporting and record documentation errors, so operational efficiency is increased.
11. Avoid mistaken identities. All data must be sorted, written legibly in ink on every page of history, not erase or use white correction fluid (tipex®). If a mistake is made, it should be amended outside the page of history, and account for the correct indication. Errors can include any alteration in the links of the health team, as well as mistakes in terms of: diagnosis, medications, equipment, laboratory reports, radiology reports, surgery and others.
12. The nurse may be the best tool to optimize the health system and avoid mistakes, this can be achieved by creating an atmosphere where all employees can report eventualities occurring in medical practice without feeling victimized by verbal abuse authority that often exists in hospitals. When nurses feel that their superiors do not respond to their concerns, not only fail to report incidents and adverse events, but begin to ignore dangerous mistakes; which inevitably impacts on the health of the patient.
13. The physician must overcome the embarrassment that it causes a mistake, because it prevents you from changing their views about their mistakes, it is considered very devastating as it makes the person feel vulnerable and sometimes even degraded . If the doctor is unable to see their own personal shortcomings, work with others to repair flaws in the health team and recognize their mistakes and correct them will be very difficult to overcome the shame.
14. Some generic drugs are not as effective in its pharmacological effects as brand-name drugs manufactured in laboratories recognized, remember that many doctors tend to recommend equating the two groups results in generic medicines with trademarks; but when patients compared the same drug in two different business houses do not get the same result or effect on your medical condition, placing the patient in a situation of danger. It is necessary to compare the formulas to assess its effectiveness as there are many reports of international pharmaceutical companies that dilute the active ingredients of drugs or medication, in order to obtain an economic benefit.
15. Never leave the patient. There is a new "culture of rush or hurry" in the doctor / patient / time relationship; whereby often not looking to find quality but quantity and it is a dangerous detrimental to the health of the patient. Inaccurate or rapid questioning where skip important details can give way to a misdiagnosis, which consequently give a bad treatment. "The best patient is one who is awake, conscious, alert and wisely want to participate in their own health and healing" (Mark Victor Hansen)
16. To strengthen the supervision of doctors in training to detect and correct faults in time, instill sensitivity to this type of problem in order to learn how to report them, discuss them in a professional atmosphere and fix them. Encourage the principles of equality, liberty and fraternity.
17. Demystifying the "taboo culture" about avoiding medical error discredit the doctor to colleagues, patients and families, promoting a positive environment supported by legal advice and hospital ethics committees.
18. Preventive measures in transfusion medicine and suggestions surgeons to avoid forgetting foreign bodies during surgery, is documented in the respective pages.
19. Perform a "Checklist" in theaters as a simple checklist of errors to check for errors, is a tool designed to reduce mistakes caused by limiting potential memory usage and care of human beings, will help ensure consistency and completeness in carrying out a task, and use goes from the surgery, through cardiopulmonary resuscitation to check hygiene measures in intensive care units. These so-called "error checklists" also exist on the computer when to give a diagnosis and uses an intellectual program based on symptoms, patient data, and indicates the probable causes of the condition.
SPECIAL CONSIDERATION TO PREVENT MEDICAL ERRORS DURING A MEDICAL GUARD.
Eventually in medical guards must meet the most impaired patients with the most precarious means, occasionally with the most inexperienced staff, the most ungodly hours in the days when almost nobody works, and the special case of surgeons the struggle for the shift in the operating room of urgency. In short, it is a hard, unpleasant work, at the wrong time, poorly paid, uninteresting professionally, painful, which consumes a lot of mental, physical and emotional energy. Finally, a personal and professional burnout; Many studies support that work between 24-32 hours in length facilitates the commission of errors of judgment and increases patient mortality. We have tried to summarize the most important points to consider when a physician be on call:
Observe and ask: Before any doubt, the doctor should be honest and humble pride aside and ask.
Review the pathology before the guard: Prioritize issues medical and surgical emergencies.
Preparation and timeliness: Arriving early will give the opportunity to better meet patients and saving time going forward what has been withheld.
Organization: You should know the team and the hierarchy and the abilities and limitations of each.
Informed: Once the allocation of work areas should try to get to know everything about their patients. You never talk about the patient's "X" bed; They must be identified by name as this will minimize the risk of error.
Education: The analysis and diagnostic investigations should aim to confirm and not to diagnose, the doctor must analyze the cost / benefit.
Delivery on duty: Delivery of guard must be made in an updated, w
Belly full, happy doctor: Avoid the long hours of fasting, food provides energy and the opportunity to socialize with the team informing news, contingencies to reorganize and prevent errors.
Do not take "selfies" Be very careful and respectful of videos and photographs during the watch, usually do so without the patient's consent is considered disrespectful and is punishable by law and ethical codes. If the doctor should do it for academic reasons you must apply for voluntary informed consent of the patient.
A bed: After the long day on call the doctor should be honest with yourself and valued; avoiding the rolls because they will be more alert and less somnolent.