Medical error. An ethical problem.
It would have been shocking to think that societies in which a newborn with a physical defect was removed her life, as well as in ancient Sparta when infants were not healthy enough, were left abandoned on Mount Taygetos. Sparta practiced eugenics, birth Spartan child was examined by a committee of elders on the porch, to determine whether it was beautiful and well formed, otherwise he was considered a useless mouth and a burden to the city. Consequently, you are led to Apotetas, rather than abandon, at the foot of Taygeto´s Mount where he was thrown into a ravine.(24)
Ethical values change over time and space, for each society and time there have been differences, the human being is able to be critical, to question, discuss and reach consensus on desirable values for their community; when someone believes he has the absolute truth, then problems arise. The different moral standards in the world have emerged from various agreements. There is a work in literature that clearly chart what we are pointing out, this is the book of John Irving American writer "The Cider House Rules" , which was a bestseller in 1999 whose script for Oscar-winning film version. The film tells the story of an old doctor who was responsible for a rural orphanage that women give birth and their babies are abandoned because they were the product of unwanted pregnancies and abortions. Over time, an orphan who was never adopted, became assistant to the doctor and learned what the old master taught medicine empirically, however, the young man would refuse to take care of performing abortions, only attend births and collaborate in the rest of the care of the orphanage. Later that young orphan, leave the laborious life of the orphanage to work as a collector of apples in an orchard where he is forced to help a teenage abortion raped by her father. It is then, when at that moment understands that the rules written by people who have not experienced firsthand the real conflict which involves an unwanted pregnancy and return to the orphanage to replace their old master made abortions and births. Around the decade of the years 1940 - 1950 in the United States experiments on humans, whose population consisted of indigenous prisoners, nursing mentally alienated and children were conducted, the research involved injecting four syringes with pathological material to test the clinical course and treatment response in sexually transmitted diseases (syphilis, gonorrhea and others), there is currently a dispute over 83 deaths, survivors sick, blind and joint problems; and Rockefeller Center, Bristol and Pfizer Laboratories are involved who deny any responsibility claiming that tested drugs as treatment. (25,26,27)
ETHICAL CONDUCT, MEDICAL ERROR AND MALPRACTICE
"Modern science has not yet produced a calming drug is as effective as a few kind words." Sigmund Freud.
The codes of ethics are a tangible expression of professionalism, certainly the phrase "to err is human" is perfectly applicable to physicians, who are no different from the rest of humanity. When doctors make mistakes, they can have many consequences, sometimes without clinical repercussions, but sometimes directly impact the health and quality of life of patients, there are certain mistakes that endanger the life of the patient and other they can culminate even in death. There are conditions as already mentioned, so that doctors make mistakes which include stress, fatigue and distraction at the time of the medical act. The risk of errors related to health systems, related to the efficiency of administrative processes such as misplacing records or laboratory tests, laboratory analysis report incorrectly or wrong tests that belong to someone else, not having special studies for the moment clinical examination or treatment, among others. (28,29,30)
The ethical debate focuses on whether or not report it to the patient, and the barriers that are usually found unwillingness to admit by the physician, the implications this may have among their colleagues and the fear that doing so , can lead to lawsuits or other legal actions. (31,32,33)
An interview with the author of "The error in medicine. Clinical autopsy as an instrument of care quality ", the specialist in Anesthesiology at the University of Salamanca Rebecca Martin Polo, exalted, that prevent communication of medical errors prevention difficult. In some countries, where the health system can and conceives admit medical error and report in the medical history of the patient or other document facilitates correction, prevents recurrence and may even be a mitigating factor in legal cases where the mistake comes namely by other sources. (34,35,36)
Generally, the law recognizes that doctors can make mistakes, as long as there is no negligence, but the interpretation of this is, however, very variable. It is always advisable, it is he who report the error to the patient and objective and narrative explanation, defensive or evasive but regrets recognizing that occurred. Addressing this point, we have created internet portals such as www.sorryworks.net which show that, surprisingly, both doctors and nurses historically have not been trained to apologize, and moreover, it always associated with future demands, and the fact apologize is to admit that a mistake was made; however, there is a big and important difference between demonstrating "empathy" or "empathize" and apologize. You can show empathy when it says: "I regret that this has happened, we will conduct a review to see what went wrong and determine where was the fault, sorry for you." While apologize, express something like: " I'm sorry it happened this error, it's my fault. We will provide compensation. " Both sentences use the apology, but is connected to emotion (empathy); while another supports the ball and amend proposed giving compensation (apologize). In the United States it is advisable to all health personnel after an adverse event empathize, if you think that has happened only a mistake and apologize if recommended after a thorough review has been determined and tested their commission.
Demonstrate empathy, it is always appropriate in most cases, and both doctors and nurses must be trained in its use, as this can help a lot later. The doctor-patient relationship should try to always be preserved, even if he had raised the death. Many lawyers point out that very different results can be obtained if the physician rather than evasive behavior had not refused to communicate, noting that demonstrate empathy is the key to maintaining communication and doctor-patient relationship after a mistake. In North America, there are organizations to train health personnel to empathize with respect to the occurrence of a medical error or adverse event, the following paragraph is mentioned as exemplification to demonstrate empathy from one of these companies: "Ms. Smith completed the surgery, I know you were planning to take home to his mother in a few days to celebrate a big birthday party with the kids next week, but unfortunately the surgery did not go as expected and his mother is in the UCI. I regret that this has happened, I can imagine how difficult it must be for you. But please keep in mind that we will begin to review what happened and we would like to meet with you. Am to 3:00 pm to discuss it. Please note that your mother was attended my best and we expect progress. Do you currently there anything I can do for you. Or your family ?. Have you transport or want to make a call? This is my card with my cell number, you can phone me at any time. Again sorry for what happened, we try to fix it together. "(37,38)
MEDICAL ERROR
"Science is made up of mistakes, which in turn are steps toward the truth." Jules Verne.
Between disciplines and work performed by man, no one who requires practice, so moral elevation as medicine, and this is because doctors work with the most precious human beings who have, health and life. The medicine has a central role in the sense of certainty and "faith" of human beings, because it offers hope of reversing the suffering, disease and death in society. There are not an international consensus on the definition of "medical error" and many approaches to conceptualize are based on ethical and moral principles, linking medical ethics, duty, humanism, brotherhood and solidarity that ultimately mean the respect for human dignity.(39)
Definition
The error conceived broadly be defined as false knowled
ge we have of something, it is equivalent to the mistake, that is, you have the knowledge but tergiversating without reaching the truth. Representative of ignorance as this is, the lack or absence of knowledge; who makes a mistake or thinks he knows the correct result obtained, this being false. It may be about facts, things or ideas. From the human perspective, the error is the cause of many accidents, for example, when a vehicle is bad repaired and the car hits another. However, it is noteworthy that according to the legal establishment, this mistake should not be intended, as contrary there would be no mistake but fraud, and it must be demonstrated either the existence of negligence since then would be wrong to become fault. The awkwardness should have a motivating reason to claim that it was not a mistake and a lot less guilty or willful attitude. (40,41,42)
Mistakes made in the area of health, may cause harm to the patient and are categorized into various types, including those that occur during diagnosis (misdiagnosis), also during the administration of drugs and medications (medication errors) or when surgical procedures, use of inappropriate therapy or by handling equipment and interpretation of results are made. Medical errors should be differentiated from "malpractice" in the sense that they are accidents in the course of an honest practice of medicine, while the "malpractice" is the result of negligence, ignorance, incompetence or criminal intent . Among the types of medical errors, you can point out errors of commission that tend to have an immediate effect; while manifest errors of omission by the persistence of the disease or lack of cure in the time estimated to do it. According to the Institute of Medicine (IOM) in the United States (US), an adverse event is defined as "the failure in implementing a health plan by act or omission to be completed as planned without the existence of misconduct". (43,44,45)
Medicine presumes a commitment of resources, therefore, the medical error should be separate from "adverse outcome" when the doctor used all available resources without obtaining the expected success, as distinguished from "unforeseen accident." What is most striking when the so-called "medical error" occurs is the dramatic reversal of expectations of who goes in search of good and evil reaches. The harmful result, in turn, is immediately visible and generally in most cases; almost always coated singular and irreparable suffering to human nature. Many errors in other professions go unnoticed, except error by the doctor, who has been described as "professional misconduct that involved a technical failure could result in an injury to the life or health of others." In this vein it should be noted that originated from an unpredictable and uncontrollable accident result. The unpredictable accident harmful result is the product of a fortuitous event could not be foreseen or avoided, whatever the author under identical circumstances. Meanwhile, the uncontrollable result is that derived from a situation of inexorable course of evolution own case, when at the time of the occurrence, science and professionalism do not have solutions to solve it. (46,47,48)
The doctor for the diagnosis, should conform to criteria of prudence, accuracy where coexist fundamental ethical questions: To make a diagnosis? To find out, (if the reason is a scientific reason), to help (in the case in question of humanitarian grounds) for profit (is involved personal prestige) and to contribute to social order (legal or administrative consequences). Prudence in the use of technical means requires that the expected benefits of research clearly outweigh the potential harm. (49,50,51)
MEDICAL AND PROFESSIONAL RESPONSIBILITY ACT
The professional responsibility of the physician is defined as the obligation of compensation for the harmful consequences of actions or omissions committed within certain limits, in the exercise of their profession. At first, this exercise requires consideration of two legal goods health and human dignity. Secondly they are considered medical duties; comprising medical history, patient care, diagnosis, proper treatment, patient information and professional secrecy. The breach of these duties is the basis of moral and legal responsibility of the physician. The criminality, illegality and guilt as fundamental principles in all crime is remembered. The blame for the effects of medical field is defined as the medical performance involving a characteristic unlawful and carried out with violation of the duty of care action. (52,53,54)
Negligence, recklessness, incompetence and disregard of regulations, are forms of guilt. Emphasis is placed on the obligation of the doctor to know what acts should not be delegated, to avoid being punished by relegating functions that correspond exclusively to meet him in accordance with current regulations. (55,56,57)
RISKS AND POSSIBILITY OF ERRORS IN MEDICAL ACT
Estimate an exact number of medical errors is difficult because converging many factors, one of the main ones is that most of them are not reported by staff dispensing health, 42% of the general US population believes that eventually has been susceptible to an adverse event by doctors. In Australia 2.4 to 5.6% of hospital admissions are due to errors in prescribing or medication, while in the Netherlands, 180,000 annual deaths from medication errors and adverse events caused by them are reported. In the case of Venezuela, (Southamerica) there are no published statistics, however, a recent increase in complaints of affected patients to the hospital management, the Attorney General's Office, in the Commissioners closer to the patient's home, school is appreciated Doctors and even to public media such as radio stations. (58,59)
Historically societies have accepted the existence of the physician and the exercise of his activity as a benefit, and people in the community don´t know what to do if haven´t the precious resource of medicine. Persons engaged in the medical profession have always been treated with special consideration and appreciation because it recognizes them dedication, commitment to service, expertise and efficiency. But nevertheless; the practice of medicine involves risks and medical practice can cause injury to rights protected by law. (60,61,62)
The doctor should to keep the patient constantly clear, complete and accurate informed. Similarly, the patient must express his personal consent through a third party or legal representative. Given the risk that may involve any medical activity, the patient is who must take the decision and not the physician. (63)
It is important to be cautious and anticipate possible outcomes of a treatment; unfortunately the therapeutic action could be related to unwanted events. Medicine is not an exact science and not all patients respond in the same way. (64)
Factors that may influence negatively
In the US 50% of hospitalized patients may be affected by medical errors, for 1999 the Institute of Medicine (IOM) reported between 48,000-98,000 (17.26%) deaths annually due to medical errors and events adverse. Some recommendations made by the Institute, were focused primarily on reducing fatigue of medical personnel, avoid night "beatings" and encourage rest periods during the workday; it is estimated that the costs of these measures could be large and even its effectiveness is unknown. (65,66,67)
Fatigue is usually experienced in the medical as a "lack of energy" while tired or drowsy refers to a "state of alert diminished." The "Burnout" is a syndrome comprising three domains depersonalization, emotional exhaustion and low skills associated with a decrease in work performance and is related to medical errors as they occur, substantially affect the overall capacity of the professional and is likely to it make mistakes, that would not make under normal conditions. (68,69,70)
Related error in decision making
1. Limitations of human knowledge due to insufficient training. If the medical professional has not been adequately trained in the academic course will not be well equipped with the skills and abilities when making a decision that could compromise health or life of a patient. (71)
2. The accelerated development and advancement of medical knowledge with poor practice. The doctor is obliged to continuously updated in v
ocational training and responsible for knowing the techniques and diagnostic procedures or therapeutic equipment to be used. (72)
3. Uncertainty in medical decision and technological innovation misapplied each factors in the wrong indication. (73)
Related to inadequate working conditions
In medical practice, many of the failures in Latin America are caused by the precarious working conditions of health professionals. It is easy to understand what can happen in parts of medical work, where damage and casualties are increasing, while the behavior is easier to blame the doctors. Because of such reasons, one of the responsibilities of the physician should be to inform the deficiencies or poor working conditions, recording them in medical history as part of documentary evidence and report them to the competent authorities to require adequate resources. The art of healing must be exercised in appropriate and dignified environment for the patient, that protect your privacy, privacy, medical confidentiality and in short everything that safeguards the rights of the patient; the doctor may even skip some elective acts in professional practice, having meanwhile care behave prudently in situations of urgency and emergency. (74,75,76)
In Venezuela, the health system has been dramatically affected as evidenced by overcrowding of patients in any circumstances have to be treated on the floor for lack of beds, in addition to other shortcomings. (77,78,79)
CONSEQUENCES OF MEDICAL MISTAKES
In medicine there are medical procedures that can cost the patient's life, like treating the wrong patient due to a misidentification of the same, leaving surgical instruments inside your body, carelessness in monitoring patients with dementia or Alzheimer's let them be lost and being disoriented die of hypothermia or dehydration, long waiting periods in the case of patients with diseases potentially death as bacterial meningitis, acute myocardial infarction, stroke, head injury, peritonitis, acute pancreatitis, emergency surgeries, cholecystitis and sepsis; whose delay in care, diagnosis and approach can produce lethal consequences. (80,81,82)
CLASSIFICATION OF MEDICAL ERRORS
General errors can be triggered by poor communication between patients and physicians, inadequate organization of teams, neglect overhaul of equipment needed for a medical act (check assortments of oxygen, batteries, gas, laboratory services and radiology, forget verify the status and expiration of medicines and blood products, antibiotics, prosthesis, and others.) (83, 84)
Diagnostic errors are usually due to misinterpretation of the signs and symptoms, delay or mistake in diagnosis, tests or results. (85,86)
Treatment errors wrong medical treatment, performing technical or pre- or postoperative treatments defective, delay in therapeutic decision making, inadequate surgical indication.
Prevention error is caused by a bad choice of therapeutic usually in chronic diseases or not alert drug interactions, omit say to the patient how things are allowed or prohibited during the course of therapy or disease, also perform inadequate antibiotic prophylaxis (poor preparation of the colon before a colonoscopy, incorrect information on restrictions before and after this procedure , poor planned post-operative monitoring). (87,88)
Studies have been conducted in several countries showed statistics of medical errors range from 3.5 to 16.6% of the number of hospitalized patients, and that the United States is the third leading cause of death after heart disease and cancer. Unfortunately in Latin America there is very few information about it and it is likely these values are similar or maybe higher than those reported in North America. (89,90)
It is well known that when doctors performed without the necessary experience new procedures, or begin their training in a particular discipline, often make errors or mistakes, and there are risk factors to be forgotten by doctors increase their incidence, such as extreme age of patients being hospitalized in complex areas of care as those made in the Intensive Care Unit (ICU), emergency rooms and trauma-shock or a prolonged hospital stay, all are associated with a greater chance of mistakes.(91,92)
A study in various Australian health centers, found that of 14,179 hospital admissions in 1995, adverse events occurred in 16.6%; and 13.7% cases of errors. Of these, they caused permanent damage to the patient as death 4.9%, and 51% of them were considered "preventable", many of the errors were not reflected in medical history, so a computerized system was used to detect alterations in the dose of drugs or medications used. For detection of medical error, there have been highly expensive observational studies have identified high error rates and damage occurred during hospital care. (93,94)
There are mistakes in medicine today causing a significant morbidity and mortality in hospitalized patients. In the literature, 54 hospitals in Vermont (USA) developed an anonymous Web site to report errors, quasi-errors and adverse events. For almost 17 months 708 events were reported errors in the choice of medication in the dose indicated in nutritional infusion speed and transfusions received or not by the patient; also in administration or method of treatment 14%; in patient identification 11%; retardation in the diagnosis 7%, mistakes during the operation or procedure used 4% that such anonymous reports were analyzed at the end it became clear that the main contributors were misleading; the neglect of the sick 27%; problems of doctor-patient 22%; failure data collection, anamnesis and physical examination contained in the medical history or patient identification 13%; medical inexperience 10%; error in the labeling or marking of drugs 10% and poor teamwork 9%. A human mistake indicates in most cases, a lack of training or a failure in the way of acting in a given time; but the collaboration of the entire team of health workers is indispensable to know the facts and circumstances in order to correct them. (95,96)
For their part, medical professionals in US hospitals, carry their own records and give their opinions on adverse events occurred, and also think about the quality of patient care at these centers. Research in the US during the years 1995 - 1996 using a computerized system, showed that the problems were at hospital acquired renal failure, hyperkalemia, hypokalemia and digoxin poisoning. When we proceeded to analyze the factors involved, the following: more than 69 years old, male, more than 10 days hospital stay, hospitalization due to surgical, cardiovascular or respiratory disease, were found within the first factors of morbidity and mortality; and he concluded that certainly must take steps to improve the health system, since errors affecting cost to the institution, the state and patients. It has been shown that some health professionals, are reluctant to participate in research and discussions concerning medical errors as difficulty associated, there is a limitation that a large part of medical errors are not documented in the form of new or in medical history or they are not identifiable. (97,98)
There are authors who disagree with what was reported by the Institute of Medicine (IOM), and who claim that the results of the institute are not well substantiated data; given that the Institute of Medicine is a state agency directly responsible for the health security and these statistics estimated based on studies conducted in hospitals in the United States located in New York, Colorado and Utah in 1992. (99,100)
It is estimated that in North America, adverse events occur between 2.9 to 3.7% of hospitalizations, the study may underestimate the number of adverse events for two reasons; the first is that only few cases that have been documented in the medical record and the second is that we study only those patients who remained hospitalized are included. There are researchers who have studied the prevention and biosecurity in health as Hofer and Hayward, saying that we must take action in those deaths or those who can actually damage avoided. Scientists have found much difficulty in reviewing both medical and surgical histories, and categorize if it was an adverse event, medical mistake or error involving the entire health team. (101,102)
LEX ARTIS
"Every
time I make a mistake I seem to discover a truth he did not know." Maurice Maeterlinck
The term lex artis comes from the Latin "Law of the art" performance or technical rule of the profession in question. The health professional to act within the parameters of this law, must master the subjects studied in his career, that is, have the necessary knowledge and enforceable to practice medicine without temerity; otherwise take the patient to aggravate their pain with danger and serious risk to their health and life, that is why the Law of Medical Practice requires doctors to be constantly updated and renewal of knowledge to provide better quality health delivery, so the doctor may use all means most appropriate diagnoses within its scope, interpret and apply the benefit of the patient. He also achieved the scientific prevail on economic criteria favoring the choice of appropriate treatment, careful implementation, enforcement and monitoring. (103,104)
The principle of lex artis, usually applied to professions that require an operative technique, and in the field of health says the techniques for each type of medical procedure such rules, these rules or clinical procedures should be tempered to the case, he never there are two identical patients.(105,106)
The german legal doctrine asserts that the medical indication and the lex artis, are two concepts that are strictly related but are essentially different. While the medical indication answered "yes" to treatment and determines whether to apply this or any other measure; the "lex artis" refers to the "how to do" of the treatment, the procedure or method to be followed. Malpractice contrary, implies a breaking of the rules, out of the way of "good work", a deviation of the medical act. (107, 108)
The medical act, is the activity of diagnostic evaluation, treatment, prescription, prognosis or implementation of measures to ensure the health of individuals or groups of communities exerted by a physician with freedom of choice and consent subject or population, being obliged to repair the damage caused in the course of their professional activity. The legal basis is the legal and social needs to answer for damages caused by intentional or unintentional but foreseeable and avoidable misconduct in the exercise of their profession. The medical act is such a contract to provide services, which can rise to the entitlement to claim if you have not met or met poorly with the provisions of that contract. If during the course of treatment, his fault causes damage to the patient; the physician must repair it and that responsibility has its budget in the general principles of discernment, attention, freedom and law. (109,110)
MEDICAL DISPRAXIS
The term medical dispraxis means alteration of medical practice; while medical malpractice expression should be used only when the judge so determines, in these cases the physician causes damage as a result of his wrong action, wrong use of a technique, inexperience or ignorance. (111,112)
There is also a term called "honest mistake" which means that in reality doctor don´t intend to cause harm, but because of the existence of multiple factors at a given time, can affect medical practice. (113)
Within the context nosographic find the term iatrogenic, meaning any alteration of the patient's produced by the doctor; composite concept, born of the "iatros" greek meaning doctor and "genea" origin. (114)
MEDICAL MALPRACTICE
Medical malpractice as an beatable inadvertent error, a defect in the application of methods, techniques or procedures at different stages of the medical performance, resulting in an impairment that was foreseeable health or life of the patient is defined. To be configured medical malpractice the concurrence of three indispensable elements is necessary:
• Evidence of absence
• Evidence of damage
• Causal relationship between them.
WHY DOES MALPRACTICE?
There are multiple causes which can cooperate in the crystallization of medical malpractice; however, the most outstanding because of their everyday are:
1. Poor doctor-patient relationship. It is shown that when there is a good relationship between the physician and his patient, medical claims are lower, perhaps by understanding the pathology of the patient or their family, for kindness, or find empathy for their discomfort or illness. (115)
2. Erroneous development of a history. The history comprises the means by which the physician collects part of the biography, anamnestic and physical examination data, in order to obtain a presumptive diagnosis, lack or absence of data in this document, difficult access to knowledge successfully the disease entity affecting the patient. (116)
3. Poor communication between the health team. The consistency and unity of all members of the health team, is one of the fundamental pillars for the proper management of the patient; it is through the integration of data, communication of eventualities, possibilities allergic, drug interactions, emergency requirements and other tests that can alert the need to accelerate or steer a study, readjustment of drugs or antibiotics; even avoid the need for expensive examinations and surgery. The bad or even no communication between the members of the team, not only add more stress in the workplace, but lack of "rapport", mistrust and in turn will affect the recovery of sick or cure. (117)
4. Disgraceful working conditions, poor financial remuneration for the work or work performed by the doctor and the rest of the support staff of medicine, translate into an unmotivated team work, resentful, outdated, malnourished, in poor quality daily, risky high social insecurity for life. (118)
5. Inadequate monitoring of the patient. Periodic assessments of the patient become important especially in the case of patients at risk or who have had life-threatening illness or who have left important consequences. (119)
iatrogenic
There is variety of positions on this concept, the physician who is considered iatrogenic causes not attributable, some people say that is not synonymous with medical error, while others say yes. The term iatrogenic is not yet in medical dictionaries; only the adjective "iatrogenic" refers to "all alterations in patient condition produced by the doctor, even when applying a treatment indication is right." It is the result of an unforeseen event, which defies chance of being avoided by the usual means of individual or collective care, and in principle does not derive from the will or fault of the doctor. (120)
Classification of iatrogenic:
• Iatrogenic positive: When alterations are harmless to the patient.
• Iatrogenic negative: The patient's condition is damaged due to the action or medical intervention. The negative iatrogenia can be of two types: necessary or unnecessary. On the negative iatrogenia necessary the doctor has full knowledge of the risk of harm, it is something expected, anticipated, producing no surprise and it recognizes it as a possible consequence of their actions on behalf of the patient, in his determination to heal has to consider the "risk/benefit". We could distingish some examples like an urinary infection caused by the installation of a Foley catheter (urinating); feeling stomach pain because of the side effect of an antibiotic to treat a systemic infection or a thrombosis in the lower limbs after hip surgery. In the type of iatrogenic unnecessary negative medical action has caused damage that had no reason to happen, it is a consequence of ignorance and is ethically unacceptable. It is excluded from malpractice, as there have not the elements of guilt, it is also called "violation" or "medical need." (121,122)
Within the physician-patient relationship, there are elements of communication between doctor and patient or family as expressive nonverbal communication through gestures or attitudes. Iatrolalia called to words that can cause feelings of humiliation or ridicule, distrust increase, stimulate hypochondria and hurt self-esteem. Also a precipitate insufficiently contrasted diagnosis can be fixed in the patient's mind and be very difficult to rectify later this misuse of information may be due to missing or insufficient, excessive, ambiguous, distressing information, use of pop
ular terms of evil prognosis, lack of discretion, provide information through a metaphorical language incomprehensible to the patient or when it lacks the necessary empathy. (123)
There acts as amputation or removing the wrong organ, erroneously administering food intended for enteral use intravenously, they are no longer mistakes and become malpractice, because such failures would not occur under conditions of careful practice if professionals pay attention to what they are doing, while; prick a lung and cause pneumothorax when intended to drain pleural effusion, drill and cause peritonitis colon during a colonoscopy procedure, are situations that may occur if expectations have been taken and can be categorized as medical errors. Sometimes situations in medical practice is more complicated, and usually the difference between malpractice and medical error is not explicit and depends on several conditions. Making mistakes is human, hide is unforgivable and not learn from them is inexcusable.
Some time ago, the US press reported the case of a patient who attended an emergency room due to a severe headache, then, the doctors not found abnormal findings on clinical examination and considered that presented no urgent problem and after improvement of symptoms, she was sent to her home with the indication control to come to her regular doctor, the patient subsequently died as a result of what appeared to be a subarachnoid hemorrhage. This problem could have been diagnosed during admission to the emergency room by a lumbar puncture or cranial computed tomography (CT), but the indication of these tests depends on the information itself supplied to the patient and physician experience physician to suspect. If the patient had referred the doctor that this was "the most important pain head life" evidence should have been done; but on the contrary, the patient reported a history of headaches repeated for several years and did not express the current headache presented special features, such tests should not be done, because do it indiscriminately to every person with headache would do more harm than good; in this case it would be an "error of judgment", since a severe headache one slight confused and family may demand compensation for damage caused by the professionals, and physicians would be free of guilt and should not be subject to professional disqualification or criminal action. While it is true that the existing health management in health centers may have some degree of commitment that errors occur occasionally, that does not relieve the treating physician individual responsibility. Events due to an erroneous health management are hepatitis epidemic in a hospital room, by contamination of a drug solution used as a treatment in several patients, without changing the needle, thereby inoculating virus hepatitis and it aimed at reducing the hospital expenses; this situation somehow induce the criminalization of doctors responsible for the room. In Venezuela several years ago occurred an epidemic of malaria by Plasmodium vivax in Barquisimeto (Venezuela), precisely because a re-used syringe contaminated with the blood of a patient with malaria, in healthy patients. When the conditions of our work as doctors are unacceptable for good clinical practice, they must denounce the shortcomings of medical practice and refrain presenting the waiver of that job, claims and complaints must be present before and not after problems arise in order to avoid them, and don´t accountable others responsibilities you have. (124,125)
MEDICAL PRAXIS UNDER THE OPTICS BY THE EXERCISE OF THE MEDICINE´S LAW
It is important to clarify that any action in different areas, can generate responsibility to others. The exercise of medical work, have criminal, civil, administrative and disciplinary responsibility in isolation well combined; the Law Practice of Medicine in Venezuela, quote: "The disciplinary and administrative penalties shall apply without prejudice to any civil or criminal liability that may be required as a consequence of action, omission, incompetence, recklessness or negligence in the practice". The same law requires the different penalties for each type of responsibility. The disciplinary sanctions order, which provides that "The order disciplinary sanctions are: oral and private reprimand, oral and public reprimand, written and private reprimand, written and public reprimand, exclusion or deprivation of honor, rights or privileges of trade or professional ". The administrative penalties referred to: "Thirteen to sixty-six tax units and suspension of the exercise of the profession up to two years. With regard to disciplinary sanctions” competent to disciplinary sanctions disciplinary tribunals of the Colleges of Physicians or other medical professional organizations and on appeal, the Disciplinary Tribunal of the Medical Federation". We can conclude that the general theory of responsibility, is a potential partner in medical action, and therefore it can be said, that every act of man implies responsibility; which results in a duty to repair in the event that an error was committed, it generated a fault and damage to third parties. (126,127)
Dr. Mendez Quijada, venezuelan psychiatrist and lawyer, thinks that happens in this land , unlike other countries, there is a predominance of criminal charges rather than liability claims, recommends the importance of a proper doctor-patient relationship with in order to reduce the possibility of unnecessary claims as a solid relationship of trust based on honesty, selfless constant evidence of patient care within their complications and the doctor frankly, have been key elements to prevent a complaint the patient or their family. (128,129)
THE IMPORTANCE OF doctor - patient relationship
We have seen a number of virtues, that delve into the most intimate conviction and reason for being a doctor; however, in the doctor-patient a set of problems, such as confidentiality, privacy and fidelity, among others arises must be protected. Without the most exquisite attention to these aspects, the relationship with the patient is broken. It is imperative that both the dignity of the patient and the doctor are totally respected. (130,131)
Recognition and respect for patients' rights is a must in an assertive medicine, only in the framework of respect and exercise of rights component will realize the principle of autonomy, under which the patient assumes making decisions according to their own interests and values. (132)
Tancredi in 1978 defined the concept of defensive medicine as the application of treatments, tests and procedures, with the main purpose to defend the doctor of criticism and avoid controversy or any malpractice claims; but these procedures can, exceed the diagnostic and treatment considerations. (133)
It could be argued that the pursuit of professional excellence, should start from that medical acts must meet two basic requirements correction and goodness. The first quality, refers to adequate training in health care and proper implementation thereof; the second to the moral condition of the doctor, his human sensitivity and the reflection of their own ethical values in the acts performed. It is recognized that much expertise in the art of healing and kindness in the work of the doctor makes "good". (134)
From the Hippocratic oath to the Geneva Declaration (World Medical Associate), codes of medical ethics and have ignored the obligation under the truth, leaving medical judgment the amount, quality and way of giving information to patients. Judicially it has been assimilated with the revelation of communication techniques or procedures requiring decisions by consent or refusal by the patient to medical procedures. This relationship of truth is based on three pillars:
a. Respect for the human person, is intimately linked to the principle of autonomy, consent is not expressly autonomy if not previously informed the patient.
b. Respecting the duty of loyalty, keeping promises and acquired moral context of the relationship with the patient to tell the truth. This loyalty is mutual respect nature, that is, the patient agrees to tell the truth to your doctor and vice versa.
c. The doctor-patient relationship is trust and compliance rules for the accuracy, such as in the researcher / subject, is that security and confidence.
The duty of confidentiality is established when the patient agrees to the history, examination and registration in a medic
al history, renouncing an important part of their privacy to deposit in people with access to that story, but; you are bound by medical secrecy not to reveal its contents without authorization.
There are several types of arguments supporting maintain confidentiality or medical secrecy namely:
a. Based on the consequences if the patient does not trust the doctor, will not permit an adequate examination or the complementary tests, patients' rights are betrayed, admitting one exception as prevent harm to others, the patient himself or the public interest, without underestimating the validity of the latter.
b. Associated with autonomy and intimacy, is based on moral principles of respect for autonomy, privacy and personal integrity, rupture can cause serious repercussions on your personal, work, family, professional environment and even emotional disorders.
c. Involved with fidelity, it is another way to force confidentiality. There are special situations in which the breach of silence is justified and when it occurs, resulting in harm to others. It is closely related to autonomy and privacy. Fidelity is also known as professional rectitude and should be understood as the ability to meet commitments, promises and pledges made voluntarily, his expression is to respect the moral principles of autonomy, justice and utility.
Privacy is a right derived from the fundamental rights of life, liberty, property, is the limited access to information about a person, their habits, customs, habitat, feelings, relationships with people in their immediate sphere. They defend consequentialist theories, justifying the right to privacy as an instrument for personal development, creation and development of close relations and an expression of individual freedom. Finally, there is a model that upholds the principle of the autonomy of the individual and the ability to exercise independent actions as may be granting or not access to information. (135)
There are conflicts of loyalty and divided loyalties, involving the professional loyalty derived moral principle, emanating from the own way of being and commitment of the physician rather than promises, vows, oaths or contracts with the patient. Traditionally, the interests of patients above those of others and even the doctor himself has been conceived as a priority, but this ideal has not always been fulfilled, or morally is due to be met. According to other authors we cannot force the doctor to attend free all sick or endangering their lives in the exercise of the profession. (136)
Conflicts of interests of third parties also cause divided loyalties; in such a way that the structure of current health institutions often cause, according to the allocation of employee benefits for the health professional, work overload or the patient's interest conflicts with colleagues, the institution or company that places the physician at a moral crossroads before an urgent decision. At that time you should abandon or modify one of the conflicting loyalties, the only way to reconcile. (137)
Eventually happens, that the obligations of the doctor come into conflict with interests of the patient, for some religious doctrines that prevent certain therapeutic conducts its members, also in cases of intrauterine interventions in pregnant women where the interest of preserving life mother can hit the fetus. The doctor should in these cases, recourse to the judicial authority that will establish the priority of loyalty to the conflict of interest. (138)
It is common for the doctor, conflicts in their duty to the patient and the interests of the company or institution for which they work. One example is the medical personnel of companies, military or penitentiary institutions. The doctor who works for companies must observe the precepts contained in codes of ethics and should refuse to sign any contract, where he is forced to retain information that may benefit or harm the patient. (139)
Regarding the military doctor, you can perfectly reconcile the interests of the army with ethical principles, even if unjust war, because its service is provided by human beings, rather than the soldier and observes specified in codes of ethics and International declarations in cases of torture. The same doctors who serve in prison, and participation in examinations, interviews, preparation and participation in executions is applied. Using a proper epidemiological report on these adverse events or mistakes in health institutions, it is essential for prevention, and their absence hinders preventive measures are installed. (140)
why the doctors are wrong? Page 3
