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Revista de la Asociación Médica del Centro Médico ABC

2011, Number 1

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An Med Asoc Med Hosp ABC 2011; 56 (1)

Error in medical practice. What do we know about it?

Vázquez-Frías JA, Villalba-Ortiz P, Villalba-Caloca J, Montiel-Falcón H, Hurtado-Reyes C

Language: Spanish
References: 102
Page: 49-57
PDF size: 72.16 Kb.


ABSTRACT

Little has been written in Mexico about the origin and prevention of medical errors when compared to other countries. This is a worldwide topic in which physicians, medical institutions and federal governments are working in order to provide patients with a safe and quality service. Herein, definitions of error, its classification, approach and management options are reviewed.


REFERENCES

  1. Gawalde A. When doctors make mistakes. New Yorker 1999; 74: 40-55.

  2. Kohn LT, Corrigan JM, Donaldson MS. To err is human: Building a safer health system. Committe on Quality of Health Care in America. Washington, DC: National Academy Press; 1999.

  3. Brennan TA, Leape LL, Laird NM, Herbert I, Localio AR, Lawthers AG, Newhouse JP et al. Incidence of adverse effects and negligence in hospitalized patients. Results of the Harvard Medical Practice Study. N Engl J Med 1991; 324: 370-376.

  4. Leape LL, Brennan TA, Laird NM et al. The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study II. N Engl J Med 1991; 324: 377-384.

  5. Swift EK, Koepke CP, Ferrer JA et al. Preventing medical errors: Communicating a role for medicare beneficiaries. Health Care Financ Rev 2001; 23: 77-83.

  6. McDonald CJ, Weiner M, Siu SL. Deaths due to medical errors are exaggerated in Institute of Medicine report. JAMA 2000; 284: 93-94.

  7. Leape LL. Institute of Medicine medical error figures are not exaggerated. JAMA 2000; 284: 95-97.

  8. Zhan C, Miller M. Excess length of stay, charges and mortality attributable to medical injuries during hospitalization. JAMA 2003; 290: 1868-1874.

  9. Stelfox HT, Palmisani S, Scurlock C, Orav EJ, Bates DW. The «To err is human» report and the patient safety literature. BMJ 2006; 15: 174-178.

  10. Diccionario de la Lengua Española. Real Academia Española. 22a ed, 2001. http: //buscon.rae.es/drael/

  11. Spraycar M, editor. Steadman´s medical dictionary. 26th ed. Baltimore (MD): Williams and Wilkins; 1995. p. 592.

  12. Grober ED, Bohnen JMA. Defining medical error. J Can Chir 2005; 48: 39-44.

  13. Satava RM. The nature of surgical error. A cautionary tale and a call for reason. Surg Endosc 2005; 19: 1014-1016.

  14. Michel P. Strengths and weaknesses of available methods for assessing the nature and scale of harm caused by the health system: literature review. 2004. www.who.int/patientsafety/research/P_Michel_Report_Final_version.pdf

  15. Weiss PM, Miranda F. Transparency, apology and disclosure of adverse outcomes. Obstet Gynecol Clin North Am 2008; 35: 53-62.

  16. Centers for Disease Control and Prevention (National Center for Health Statistics). Deaths: Final Data for 1997. National Vital Statistics Reports. 1999; 47 (19): 27.

  17. Gutiérrez-Cía I, Obón-Azuara B, Aibar-Remón C. Análisis de los «casi errores». Un nuevo enfoque en el estudio de los acontecimientos adversos. Med Intensiva 2008; 32: 143-146.

  18. Brennan T, Gawande A, Thomas E, Studdert D. Accidental deaths, saved lives and improved quality. N Engl J Med 2005; 353: 1405-1409.

  19. Cuschieri A. Surgical errors and their prevention. Surg Endosc 2004; 19: 1013.

  20. Federal Aviation Administration. The aviation safety system. www.faa.gov

  21. International Atomic Energy Agency Safety Culture. Report 75-INSAG-4. International Nuclear Safety Advisory Group. Vienna, 1991.

  22. Gluck PA. Medical error theory. Obstet Gynecol Clin North Am 2008; 35: 11-17.

  23. Hosford SB. Hospital progress in reducing errors: The impact of external interventions. Hosp Top 2008; 86: 9-19.

  24. La Pietra L, Calligaris L, Molendini L et al. Medical errors and clinical risk management: State of the art. Acta Otorhinolaryngol Ital 2005; 25: 339-349.

  25. Aguirre-Gas HG, Vázquez-Estupiñán F. El error médico. Eventos adversos. Cir Ciruj 2006; 74: 495-503.

  26. Dankelman J, Grimbergen CA. Systems approach to reduce errors in surgery. Surg Endosc 2005; 19: 1017-1021.

  27. Vélez-Álvarez GA. El error en la práctica médica: Una presencia ineludible. IATREIA 2006; 19: 39-46.

  28. Weingart SN, Wilson R, Gibberd RW, Harrison W. Epidemiology of medical error. BMJ 2000; 320: 774-777.

  29. Leape LL. Scope of problem and history of patient safety. Obstet Gynecol Clin North Am 2008; 35: 1-10.

  30. Sharek PJ, Classen D. The incidence of adverse events and medical error in pediatrics. Pediatr Clin North Am 2006; 53: 1067-1077.

  31. Federspil G, Vettor R. Rational error in internal medicine. Intern Emerg Med 2008; 3: 25-31.

  32. Berner ES, Graber ML. Overconfidence as a cause of diagnostic error in medicine. Am J Med 2008; 121 (suppl); S2-S23.

  33. Tena-Tamayo C, Sánchez-González JM. Medicina asertiva: Una propuesta contra la medicina defensiva. Ginecol Obstet Mex 2005; 73: 553-559.

  34. Waterman AD, Garbutt J, Hazel E, Dunagan WC, Levinson W, Fraser VJ, Gallagher TH. The emotional impact of medical errors on practicing physicians in the United States and Canada. JT Comm J Qual Patient Saf 2007; 33: 467-476.

  35. Delblanco T, Bell SK. Guilty, afraid and alone – struggling with medical error. N Engl J Med 2007; 357: 1682-1683.

  36. Wu AW. Medical error: The second victim. BMJ 2000; 320: 726-727.

  37. Tena-Tamayo C, Sánchez-González JM, Rivera-Cisneros A, Hernández-Gamboa LE. La práctica de la medicina y la responsabilidad médica. Algunas reflexiones en torno. Rev Med IMSS 2003; 41: 407-413.

  38. Solomon RC. Ethical issues on medical malpractice. Emerg Clin North Am 2006; 24: 733-747.

  39. Lifshitz A. Los errores médicos. El ejercicio actual de la medicina. Facultad de Medicina UNAM. 2004. http: //www.facmed.unammx/eventos/seam2k1/2004/ponencia_may_2k4.htm

  40. Vázquez-Valdés E, Vázquez-Rossainsz E, Barradas-Guevara MC. Iatrogenia ¿error individual? ¿falla del sistema? Cir Ciruj 2003; 71: 397-401.

  41. Tena-Tamayo C, Juárez-Díaz González NL. Error y conflicto en el acto médico. Rev Med IMSS 2003; 41: 461-463.

  42. Reason J. Human error: Models and management. Br Med J 2000; 30: 768-770.

  43. Wu AW, Lipshutz AKM, Pronovost PJ. Effectiveness and efficiency of root cause analysis in medicine. JAMA 2008; 299: 685-687.

  44. Lanier W. A three decade perspective on anesthesia safety. Am Surg 2006; 72: 985-989.

  45. Firth-Cozens J, Cording H, Ginsburg R. Can we select health professionals who provide safer care? Qual Saf Health Care 2003; 12: 16-20.

  46. Vázquez-Frias JA, Cueto-García J. Presente y futuro de la cirugía laparoscópica. En: Nutrición, cirugía y terapia intensiva. Fuentes del Toro (ed). México, DF: Manual Moderno; 2004. P. 991-994.

  47. Woods D. Medical error: What do we know? What do we do? Br Med J 2002; 325: 285.

  48. Rivera-Cisneros AE, Juárez-Diaz González N, Martínez-López S et al. Estudio exploratorio sobre la enseñanza de la comunicación humana asociada a la práctica médica. Cir Ciruj 2003; 71: 210-216.

  49. McCafferty HM, Polk HC Jr. Patient safety and quality in surgery. Surg Clin North Am 2007; 87: 867-881.

  50. McCafferty HM, Polk HC Jr. Addition of «near miss» cases enhances a quality improvement conference. Arch Surg 2004; 139: 216-217.

  51. Leape LL. When good doctors go bad. Ann Surg 2006; 244: 649-652.

  52. Rosenstein AH, O’Daniel M. Managing disruptive physician behavior: Impact on staff relationships and patient care. Neurology 2008; 70: 1564-1570.

  53. Leape LL, Fromson JA. Problem doctors: Is there a system–level solution? Ann Intern Med 2006; 144: 107-115.

  54. Pitkanen M, Hurn J, Kopelman MD. Doctors’ health and fitness to practice: Performance problems in doctors and cognitive impairments. Occup Med (Lond) 2008; 58: 328-333.

  55. Walton MM, Elliott SL. Improving safety and quality: How can education help? Med J Aust 2006; 15: S60-64.

  56. Kovacs BK. Canadian patient safety champions: collaborating on improving patient safety. Healthc Q 2008; 11: 95-100.

  57. Leape LL. Errors in medicine. Clin Chim Acta 2009. Mar 18. [Epub ahead of print]. http: //www.ncbi.nlm.nih.gov/sites/entrez.

  58. Glabman M. Top ten malpractice claims. Hosp Health Netw 2004; 78: 60-62,64-66.

  59. Kaldjian LC, Jones EW, Wu BJ, Forman-Hoffman VL, Levi HV, Rosenthal GE. Reporting medical errors to improve patient safety. A survey of physicians in teaching hospitals. Arch Intern Med 2008; 168: 40-46.

  60. Pronovost PJ, Thompson DA, Holzmueller CG et al. Toward learning from patient safety reporting systems. J Crit Care 2006; 21: 305-315.

  61. Winters BD, Berenholtz SM, Pronovost P. Improving patient safety reporting systems. Crit Care Med 2007; 35: 1206-1207.

  62. Wittman AB, Park DM, Hardin SB. How do patients want physicians to handle mistakes? A survey of internal medicine patients in an academic setting. Arch Intern Med 1996; 156: 2565-2569.

  63. Gallagher TH, Studdert D, Levinson W. Disclosing harmful medical errors. N Engl J Med 2007; 356: 2713-2719.

  64. Pennsylvania Medical Care Availability and Reduction of Error Act (MCARE) Act 13, Sec 302. 2002.

  65. Butcher L. Lawyers-Say «sorry» may sink you. Physician Exec 2006; 21-24.

  66. Flowers L, Riley T. State-based mandatory reporting of medical errors: An analysis of the legal and policy issues. Portland, ME: National Academy for State Health Policy; 2001. p. 1-61.

  67. Griffen FD. The impact of transparency on patient safety and liability. Bull Am Coll Surg 2008; 93: 19-23.

  68. Heitmiller E, Martínez E, Pronovost PJ. Identifying and learning from mistakes. Anesthesiology 2007; 106: 654-656.

  69. Clarke JR, Lerner JC, Macarella W. The role for leaders of health care organizations in patient safety. Am J Med Qual 2007; 22: 311-318.

  70. Berenholtz SM, Pronovost PJ. Monitoring patient safety. Crit Care Clin 2007; 23: 659-673.

  71. Wachter R. The end of the beginning: patient safety five years after «To err is human». Health Aff (Millwood) 2004; Jul-Dec; web exclusives: w4,534-545.

  72. Joint Commission.2007 National Safety Goals. Jointcommission. org/PatientSafety/NationalPatientSafetyGoals/07_hap_ cah_npsgs.htm.

  73. Aguirre-Gas. Evaluación de la atención médica. ¿Una tarea para médicos? Cir Ciruj 2007; 75: 149-150.

  74. Catalano K, Fickensher K. Complying with the 2008 national patient safety goals. AORN 2008; 87: 547-556.

  75. Longo DR, Hewett JE, Ge B, Schubert S. Hospital patient safety: Characteristics of best-performing hospitals. J Healthc Manag 2007; 53: 188-204.

  76. http: //www.jointcommissioninternational.org/JCI-Accredited-Organizations/ Acceso: Enero 19, 2010.

  77. World Health Organization. World alliance for patient safety: forward programme 2004.

  78. Aguirre-Gas HG. Sistema ISO 9000 o evaluación de la calidad de la atención médica. Cir Ciruj 2008; 76: 187-196.

  79. Cruzada Nacional por la Calidad de los Servicios de Salud. www.salud.gob.mx/unidades/dgcs/sala_noticias/campanas/2001-01-25/cruzada-nacional.htm.

  80. Ruelas-Barajas E, Tena-Tamayo C, Sánchez-González J et al. Eventos adversos identificables en las quejas médicas. Cir Ciruj 2008; 76: 153-160.

  81. Morath JM. Patient safety: A view from the top. Pediatr Clin North Am 2006; 53: 1053-1065.

  82. Ranji SR, Shojania KG. Implementing patient safety interventions in your hospital: What to try and what to avoid. Med Clin North Am 2008; 92: 275-293.

  83. Brennan PF. CPOE: Sufficient, but not perfect, evidence for taking action. J Am Ned Inform Assoc 2007; 14: 130-131.

  84. Brunetti L. Abbreviations formally linked to medication errors. Healthcare Benchmarks Qual Improv 2007; 14: 126-128.

  85. Koczmara C, Jelincic V, Duek C. Dangerous abbreviations: «U» can make a difference! Dynamics 2005; 16: 11-15.

  86. Rubin GL, Leeder SR. Health care safety: What needs to be done? MJA 2005; 183: 529-531.

  87. Brooks J. US Medicare will stop paying for preventable errors. CMAJ 2007; 177: 841-842 .

  88. Pronovost PJ, Goeschel CA, Wachter RM. The wisdom and justice of not paying for «preventable complications». JAMA 2008; 299: 2197-2199.

  89. Pronovost PJ, Holzmueller CG, Needham DM et al. How will we know patients are safer? An organization-guide approach to measuring and improving safety. Crit Care Med 2006; 34: 1988-1995.

  90. Jha AK, Li Z, Orav EJ et al. Care in the U.S. hospitals – The Hospital Quality Alliance Program. N Engl J Med 2005; 353: 265-274.

  91. Scobie S, Thomson R, McNeil JJ, Phillips PA. Measurement of the safety and quality of healthcare. Med J Aust 2006; 184 (suppl 10): s51-55.

  92. Working Party of the Royal Collage of Physicians. Doctors in society. Medical professionalism in a changing world. Clin Med 2005; 5: S5-40.

  93. Turton C. Medical errors. Media tend to link error with blame. BMJ 2001; 322: 1422.

  94. Davis P. Health care as a risk factor. CMAJ 2004; 170: 1688-1689.

  95. Baker CR, Norton PG, Flintoft V, Blais R et al. The Canadian adverse events study: The incidence of adverse events among hospital patients in Canada. CMAJ 2004; 170: 1678-1686.

  96. Brainard AH, Brilsen HC. Viewpoint: Learning professionalism: A view from the trenches. Acad Med 2007; 82: 1010-1014.

  97. O’Sullivan AJ, Toohey SM. Assessment of professionalism in undergraduate medical students. Med Teach 2008; 30: 280-286.

  98. Karchmer S. Moral y medicina. ¿Somos robots? Acta Med Gpo Ang 2008; 6: 5-7.

  99. Fernández-Vázquez JM. Relación médico-paciente. En: Código de ética médica. Centro Médico American British Cowdray. Fernández VJM (ed) México, DF: Lito-Grapo. 2006. P. 57-66.

  100. Pérez-Tamayo R. Código de ética médica basado en los objetivos de la medicina. En: Código de ética médica. Centro Médico American British Cowdray. Fernández VJM (ed). México, DF: Lito-Grapo; 2006. p. 119-130.

  101. Longo DR, Hewett JE, Ge B, Schubert S. The long road to patient safety. A status report on patient safety systems. JAMA 2005; 294: 2858-2865.

  102. Leape LL, Berwick DM. Five years after to err is human. What have we learned? JAMA 2005; 293: 2384-2390.




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