 
122

Why doctors are wrong?

Jeannegda Catherine Valverde Farias

Egda Isbelia Farías Moya

Dedicated to the victims of error and malpractice

TABLE OF CONTENTS

Preface.................................................................................. 8 - 9

Historical background .......................................................... 10 - 11

Medical ethic in the Renaissance .......................................... 12

Medical error ........................................................................ 14, 19

Medical error. An ethical problem......................................14

Ethical conduct, medical error and malpractice .................... 16

Possibilities of errors and risks in the medical act ...................... 22

Factors that can negatively influence .................................... 24

Related error in decision making.......................................24

Medical and professional responsibility act ........................ 22

Limitations of human knowledge due to insufficient training.....24

The accelerated development and advancement of medical knowledge with poor practice............................................... 24

Uncertainty in medical decision and technological innovation misapplied each factors in the wrong indication.................. 25

Consequences of medical mistakes ......................................... 26

Classification of medical errors.................................................. 27

General errors......................................................................... 27

Diagnostic errors ..................................................................... 27

Treatment errors ................................................................. ....27

Prevention errors ................................................................27

Common medical errors in medical practice................................. 28

Factors involved in medical diagnostics............................. 31

Lex artis. Dispraxis and malpractice ....................................32

Medical dispraxis...................................................................... 34

Evidence of absence................................................................ 34

Evidence of damage................................................................. 34

Causal relationship between them ........................................ 34

Why does malpractice? .......................................................................... 34

Poor doctor - patient relationship................................................34

Erroneous development of a history......................................... 35

Poor communication between the health team.................... 35

Disgraceful working conditions................................................... 36

Inadequate monitoring of the patient......................................... 36

Differences between error and medical malpractice...............37

Iatrogenesis................................................................................... 37

Classification of iatrogenic ....................................................... 38

Iatrogenic positive...................................................................... 38

Iatrogenic negative ..................................................................... 38

Malpractice and law of the practice medicine ....................... 41

The importance of the doctor-patient relationship ............ 42 - 43

Hippocratic oath..................................................................... 42 - 43

Respect for the human person................................................ ....43

Respecting the duty of loyalty.............................................. 43

The doctor-patient relationship is trust and compliance rules for the accuracy, such as in the researcher / subject, security and confidence................................................................................... 43

Obligations and duties of the doctor...................................... 47

Disturbing elements of medical practice.................................... 47

The aggressive patient ......................................................... 48

Age and sex ............................................................................. 49

Relationship with the environment............................................... 49

Institutional factors..................................................................... 50

Violence..................................................................................... 51

The secrets revealed by the autopsy........................................ 52

Clinical pathological differences according to Goldman´s classification.............................................................................. 53

Defensive medicine ..................................................................54

Susceptibility to medical errors at intensive care units.................. 55

Mistakes in critically ill adults ..................................................... 56

Neurological emergencies ......................................................... 58

Table illustrates various diseases pointing diagnostic errors some common neurological emergencies............................................ 60

Safety, failures and latent errors in anesthesia............... 61

Errors in the administration of the anesthetic medication.. 61

 Surgery : How to avoid  medical  errors .................................. 62   
Medical  errors in  transfusional  medicine................................ 63  
Haemovigilance  system ............................................................ 64  
Immune reactions in  transfusions..........................................64 - 67

Failed component management............................................. 64 - 67

Incident void or "near misses"............................................... 64 - 67  
Causes of  errors in  transfusional  medicine..................... 64 - 67

Serious medical errors in transfusion medicine..................... 64 - 67

Post transfusion immunological reactions ..............................64 - 67

Statement of claims against medical staff .................................... 68

Trial and medical legal allegations............................................ 68

 Medical  narcissism..................................................................... 69

The Lucifer effect. Good and bad doctors ..............................71

"Omerta" policy in the health centers .............................................74

Discussion of medical errors and adverse events ................... 75

Comparison of the different attitudes of physicians and patients regarding a medical error ..............................................................76

What you should not say or do before a medical error................... 78

The trial against the medical error................................................ 79

Negligence.............................................................................. 80 - 81

Vicarious negligence...............................................................80 - 81

Malpractice............................................................................. 80 - 81

Failures....................................................................................80- 81

Intentional crimes..................................................................81 - 82

Unforeseeable circumstances............................................... 81- 82

Compensation due to errors ....................................................84

How to deal with medical malpractice........................................ 84

Medical malpractice lawsuits....................................................... 85

Medical obstinacy.......................................................................... 86

 Medical history.  Prophylactic tool .............................. .............. 87

 Preventive strategies in  diverse specialties ................................. 88

Surgery ....................................................................................... 88

Unnecessary surgeries.............................................................. 89

Infectious diseases....................................................................... 89

Anesthesia.................................................................................. 89

Transfusional medicine.............................................................. 91  
Suggestions to  avoid bad  praxis............................................. 92

Never lie ................................................................................... 92

Be cautious .............................................................................. 92

Acquire expertise and skill ...................................................... 92

Recognize the limits and capabilities...................................... 92  
The  patient as  active agent in the  prevention of  medical  mistakes ..................................................................................... 95

When and how count .......................................................... 100  
Conclusions................................................................................. 108  
Recommendations...................................................................... 114

Universally it considered that doctors do not have the reputation of being the best listeners............................... 120

Prophylaxis of medical error................................................. 128

Prescription.................................................................................128

Distribution ................................................................................ 128

Administration ......................................................................... 128

Follow up ................................................................................ 128

Control and management systems...................................... 128

Prevention of errors during the medical guard ................. 129

Bibliographic references............................................................ 131

Preface

In the practice of medicine, there are many occasions where the doctor must make decisions that compromise the life of patient and in which few times wondering if them will bring negative consequences. This attitude is intimately linked to medical ethics and one of its most important aspects as it is, the responsibility of the profession. In times of danger to life the ideal behavior adopted should be always obey the principles of respect for life, human integrity, preservation of moral, health and law. If the conduct that was chosen is not correct, it can be concluded in error or medical malpractice, with negative consequences for patient and physician. (1)

It´s imperative to understand that error is a logical possibility in different human activities and medicine is not exempt from this. Therefore, the possibility of being wrong should be assumed as a professional responsibility. Mistakes in medicine are usually associated with medical malpractice, but the medicine is an inaccurate science, since the doctor works between uncertainty and risk, sometimes risky treatments are needed to save a life. However, is supposed to be who practice with scientific expertise and experience, able to protect the health of a human being; the trust and good faith deposited by the patient must therefore prevail.

The term "medical dispraxis" includes all the alterations that occur during medical practice, that is, errors, adverse events, iatrogenic and malpractice. A medical error is considered as such and is not punishable must lack fraud and elements that correspond to negligence, recklessness, incompetence, failure to comply with the rules and regulations and this must be determined by a judge, on the basis of the elements of conviction. (1,2)

In the context of elements that can disrupt a good medical practice, factors such as a poor doctor-patient relationship, inadequate preparation of medical history, failures in the academic and interpersonal relations between doctor and health care team, are designated deficiencies of inputs as well as lack of stimulus for wages low and unworthy.(1-3)

Since the early days of the creation of humanity, the history picks up the existence of legal provisions for the exercise of medicine dating from 1700 B.C. Hammurabi, King of Babylon promulgated a code of laws relating to the medical practice, and Hippocrates of Cos (460-360 B.C.) developed the "Hippocratic Oath" until our days. Venezuela have the "Law of the Practice of the Medicine" which regulates the performance and liability of the physician to third parties.(1-4)

Industrialized countries annually reported comorbidity caused by errors, adverse events and malpractice. In Latin America the information is precarious due to lack of epidemiological statistics.

HISTORICAL background

"The cautious seldom are wrong." Confucius

Around 1770 B.C. Hammurabi, King of Babylon, issued a code of laws and provisions to regulate the conduct of the physician that included a large number of provisions relating to the legal professional practice. Curiously, there is not spoken morality or immorality, but the possible ill effects of an intervention, without greater discussion was passed to the imposition of a penalty. For example, the code not contemplated any appearance of ethical reasoning or moral responsibility, putting immediate legal coercion to leave well regulated and specified situations to consider. "The Code of Hammurabi, establishing clear rules on the practice of medicine:..." If a doctor causes serious injury to a patient with a surgical knife and kills him; you shall cut the doctor hands". In Egypt and Greece, there were secret medical colleges, where is stipulated the rules about the healing art and were structured regulations characterized by the severity of the sanctions, including even the death penalty. As recorded in assyrian clay tablets, the physicians of that time never accepted the incurable sick care. In terms of severe corporal punishment which specified the code of Hammurabi to medical errors, and most extraordinary that they seem to us, they were in concordant with those established in other professions in order to regulate the faults of people against others.

In China, initially the medical care was perform by humanitarianism, without any social or economic incentives, there was exercised by rulers, scholars, nobles, and priests. Medical knowledge were considered as a secret power, and could only be transmitted from fathers to sons or very qualified people socially and morally. (5,6)

The medical act is in essence an ethical act, but its controversies and its foundations could be different according the historical moment, religious beliefs and social conventions. The physician in his healing work should be guided by two principles man love and the love of his art. He is responsible for complying their duties with the patient, their colleagues and the society. Hippocrates of Cos (460-370 B.C.) who was born in the Ionian island of Cos, son of Heraclides and Minarets, learned the art of healing from his father and although history has doubt on the existence of Hippocrates, references of Plato and Aristotle assert that not only lived, but it was the outstanding physician of his time. In such a way that the Hippocratic oath includes ethical matters, surgery, professional secrecy and commitment within their philanthropy , egalitarian condition of care regardless of nationality, status and fortune; the comfort of the adjuvant patient's medical treatment, free charity to the poor sick and support the moral and therapeutic assessment of living with pain, considerations that are contained in the ethical code of medicine. (7,8,9)

MEDICAL ETHICS IN THE RENAISSANCE

"We are all very ignorant, what happens is that not all ignore the same things." Albert Einstein

During the Renaissance, it repudiated all kinds of medical practice that does not pass through the filter of university education. On the other hand, epidemics of "morbo gallico" (syphilis recrudecence) forcing doctors to think, that not everything was in the knowledge of the ancients, but that nature hiding secrets that could make evident at different times and even more, led them to propose a possible degeneration in humanity, by making it susceptible to suffer new and terrible evils. As a result joined knowledge, the contribution of personal experiences of physicians, concluded that if indeed, the medical art included in its general premises, also should enrich the individual scientific knowledge. During the Renaissance, a good percentage of the social reputation of the good doctor, was closely related to the type of clientele that had and his way of handling the collection of fees. He should be cautious and precise when charging, and appeasing recovery in chronic diseases, not so acute evils or possible quick outcome, this criterion was changed with the passing of time, the innovation of technologies and the emergence of new medical specialities. (10,11,12)

Likewise, in antiquity the quasi-sacred nature of medicine, was symbolically implicit during the first approach of the doctor to his patient, where was a priestly formality and its appearance should make you remember the patient the image of Christ and his Holy healers disciples; the doctor should be benign, merciful and charitable even to not charge to poor patients, practice that - in some cases - has remained with the passage of the years.(13,14)

The responsibility of the physician begins with the Hippocratic Oath when he graduated, which means it should be the good performance of the medical profession, enrollment in a school and the relationship with the patient which is contractual in nature, existing in her duties of loyalty, professional secrecy and compensation where a damage. In general, it is accepted that the doctors who most make mistakes are the newest, those newly graduates, primarily those who are in the first years of training and conducting autopsies and anatomoclinical sessions allow the recognition of the error through continuous learning, on the control of medical failures and the behavior of diseases. There is scientific evidence, that one of the main factors associated with the error is the age of the patient, occurring most frequently in the extreme ages of life (pediatric and elderly patients); as well as complex surgical procedures. (15,16,17)

In almost all medical errors involving his performance, the accompanying equipment and other factors, for example, has found that sleep deprivation doctor during the guards, the possibility of serious errors after more than 24 continuous hours of work. Failure to sleep or the impossibility of proper rest affect the psychomotor performance of a professional, is similar to an individual who has ingested alcohol (blood alcohol level> 0.08%). Similarly noted as a risk factor for fouling, poor communication between doctor and patient when it distorts the information provided in medical history during the care process, however; traditional techniques of anamnesis and physical examination remain key in the control of misdiagnosis. (18,19,20)

All medical specialties are likely to make mistakes, however, those specialties where diagnostic uncertainty is evident and where a delay or error in diagnosis is most obvious is surgery, emergency medicine, intensive care, anesthesiology and internal medicine. During the course of medical practice, errors often occur in prescribing a certain drug, it is part of the medical act and involves the prescribing physician with other professionals, errors that occur in this "chain" are potentially harmful to the patient for the damage they can cause by management or not the right medicine, toxic effects generated by these drugs, the absence of the expected benefit and cost to the patient. (21,22,23)

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 knowledge 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 vocational 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 popular 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 medical 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)

OBLIGATIONS AND DUTIES OF PHYSICIANS

Some of the following obligations and duties are contained in the laws and moral codes of the art of medicine; while others arise from current legal requirements given the evolution of our society, among them are professional secrecy, provide adequate technical information to the patient, voluntary informed consent, the obligation of knowledge, diligence and by the physician, continuity in treatment, assistance and advice, certification of disease and treatment as well as birth and death. (141)

Each and every one of the actors involved in the medical act, are individually responsible for the universality of the damage, with power of the judge, or except to attribute to each of the health workers to a greater or lesser degree and establish the percentage of responsibility for the harmful event. (142)

Eventually a doctor can acting against the wishes of a patient, for example, to save his life, can reach face disciplinary and criminal courts because of the principle of autonomy is nothing more than the moral right to govern; and this can lend itself to such conflicts of professional and ethical naturally. (143)

DISRUPTIVE COMPONENTS OF MEDICAL PRACTICE

Negativity accepting therapeutic maneuvers.

Among the conflicts that often arise during the practice of medicine, there are those of religious type, a common example are called "Jehovah's Witnesses", a fundamentalist Christian group that refuses to accept the transfusion of blood products yet when the patient's life is at risk, and the decision involving children or patients whose health is critical and although currently there are resources in the medical arsenal such as erythropoietin and autologous colloids.

There are real emergencies that threaten the patient's life for example: septicemia complicated with disseminated intravascular coagulation, hypovolemic shock, where it is urgent blood transfusion to the patient; and although such decisions involving the indication of a blood derivative, is a starting point for complaints from this religious group, medical staff should not forget that the Constitution of the Bolivarian Republic of Venezuela provides protection to life as an inalienable legal right, so that the doctor would be covered in the event of having to make an emergency decision at a particular time, if a patient is brought to a room Emergency unconscious by hypovolemic shock. Similarly, the Venezuelan Organic Law for the Protection of Children and Adolescents (LOPNA) notes that prevails before the autonomy of legal personality and the physician must act accordingly. (144)

THE AGGRESSIVE PATIENT

In Latin America, one of the issues becomes more important is violence in its different forms and manifestations, which has individual and collective impact. According to the literature, one of the employment sectors most at risk from exposure to aggression is the health sector because health centers are places where great activity and emotions related to life, illness and death is handled; this entails close interaction between health personnel, family and patients, sometimes trigger conflict and violence. (145)

In the psychological context, violence is a form of inadequate response that arises as a secondary reaction to different emotions no defense mechanisms appropriate to the particular situation of frustration, loss of a loved one, anxiety and fear of being despised. It constitutes a maladaptive response type and level can range from a verbal response as insults and recriminations are to physical attack and this depends on several factors. (146)

1. Personal factors

Age.

Being young is a risk factor for violence, and that the younger you are fewer defense mechanisms to conflict situations in the same way, a young doctor has less experience in dealing with such difficult situations and likewise the younger the patient, can be adolescent of adequate defense mechanisms to deal with conflicts.

Sex.

There is a slight bias of male aggression on women and is linked with life experiences in childhood (especially in case of history of abuse during childhood), degree of prior successful life experiences, the immediacy of reactions, appearance physical.

Relationship with the environment. There are factors that encourage aggression as the work alone, without other professionals who can give notice to the authority of the state of aggressiveness, work with the public and stressed or loaded contact with a high level of anxiety individuals. The sense of danger perceived by the victim, the psychological situation of the actors of the doctor-patient relationship, and expected and feared consequences; and the perception of acquired rights.

Institutional factors. Institutional climate of the unique physical characteristics of the hospital where no comfort is given and an environment appropriate and organized waits, delayed patient care in turn generate more stress on it, and he sees no response to your request for service health, and cultural and political aspects of the enclosure and its projection to society.

The personality of the patient and physician at risk for aggression (temperament) among which mention the most important passive aggressive personality, paranoid, compulsive, histrionic, borderline or borderline, antisocial personality, attitudes and expectations.

The clinical situation there is greater risk in emergency services and institutions that foster a prize to the aggressiveness of the public (patients and families) and staff accordingly.

Target recognition physicians should focus on what is really important and rethink the objectives in the doctor-patient relationship. (147)

Proposed new relationship is sometimes necessary to propose to the patient who treats other staff, however this option should be used as a last resort and unfortunately is not always possible.

Control measures and prevention, ranging from proper reception to the patient, avoiding delays, keeping rooms unsaturated expected and even if possible with a quiet and relaxed atmosphere avoiding discussions. If possible, the patient should have an initial contact or greeting with health personnel and can be helpful to train health personnel with tools for self-control and approach so learn to avoid being carried away by negative emotions. Use self-control maneuvers as "counting to ten" or "emotional counterbalance" (which is to impregnate the patient with a balanced emotional climate of peace and avoiding any drop in the climate of aggressiveness time). (148)

Customizing messages should show the patient the importance we give to you in time and also showing interest in helping, as a rule in the initial interview the examiner should always think and prioritize their personal safety, must shed necklaces, earrings, glasses, ties before starting an interview with a potentially aggressive patient and eliminate the patient's view of an object which may come to be used as a weapon (pencils, pens, syringes, scalpels). The doctor must notify the medical team, when they will interview the patient, to put alerts staff to any need for intervention by the security personnel and conduct an assessment never alone with a violent patient.

Violence is a dyadic process, according to this, the behavior and pre-verbal elements of communication examiner may induce or prevent violence, should speak so slowly showing a calm demeanor, showing interest in whatever the patient says, without ignoring or criticize what it communicates. The violent or aggressive patient should never be considered whether it is armed, in these cases, should be given alarm to security personnel or the police. Within a few recommendations to these aggressive patients they are: Never back to a violent individual, keep your hands in view of this individual, avoiding abrupt or sudden movements, please out of reach of the beating of the patient, never try to touch him when aggressiveness. Early signs of violence are talking about a faster way, raise the tone, sarcasm, wandering, refusing to take a seat, jaw clenching. When a patient is very agitated or irritable, it is impossible to reason. Specialists in the field say that "In the midst of aggressive reasoning should be avoided." (149)

THE AUTOPSY REVEALS SECRETS

Unfortunately the autopsy is increasingly obsolete, and even replaced in some countries by the so-called "Virtopsy" (virtual scanning technique) that can "discover" oversights or errors in diagnosis. In the US in the early 70s, only 20% of the bodies were performed autopsies and today it is estimated that only 8.5%. Perhaps it is because the autopsy reveals often medical errors and exposes professionals and hospitals. Moreover, for the bereaved and those close to the deceased people, the idea that the body of a loved one is dissected it is unpleasant and even some religions such as Islam and Judaism reject this procedure postmortem, so, science has come to virtual autopsy and postmortem imaging, as a routine procedure in the US, Australia, UK and Japan. (150)

They have been conducted in patients who died in the emergency area, and autopsies performed on these bodies, diagnoses had not even been suspected, such as malignant tumors, hemorrhagic pancreatitis and in almost half of cases are found there was a discrepancy important from the report of the autopsy and clinical diagnosis. Studies show that in the Private Hospital of Cordoba (Argentina), 53 autopsies were reviewed clinical cases in adults from January 2005 to June 2009 Goldman classification applied to establish clinical-pathological discrepancies between pre and post mortem diagnosis. The most frequent clinical diagnoses were respiratory infections and acute pulmonary thromboembolism. While the findings of autopsies usually found showed respiratory infections and acute myocardial infarction. 17 major discrepancies, and 30 matches were detected, respiratory infections were the main cause of failure followed by acute myocardial infarction, being the first who were the main type of error, so in this study suggests adopting information strategies and education to upgrade the autopsy and traditional clinical practices. (151)

Recent studies have found that about 25% of the diagnoses of causes of death are wrong, and the autopsy which is useful to help correct many of the death certificates. Comparing the results of clinical diagnoses with autopsies in Spain, 52.1% of errors was found in death certificates and autopsy 24% in those hospital certificates based only on clinical criteria. This discrepancy rate between clinical diagnosis and autopsy finding were held constant for over 30 years, although the medicine currently has more advanced features. Of all medical errors, diagnostic errors and costly comprise a substantial fraction. (152)

THE DEFENSIVE MEDICINE

Although mistakes in the medical field are eventually unforeseeable and unavoidable always be latent, and working conditions in which the health care team to unfold, will be a major influence that can serve as a "trigger" of unsafe acts or "risky" in medical practice. In our modern society, the collective unconscious has idea that health problems, whatever be solved and always must have a happy ending, not otherwise agree and when it does, then you have to find someone to blame "the doctor". (153)

Error given a punitive treatment, the doctor guilty, so we tend to avoid communication because any favors. The doctor passes a social media-lynching emitted prejudiced verdicts and lengthy legal proceedings; so that later, in most cases, remains cleared. The doctor is alone, without support from peers and institutional and personal level through a series of psychological disorders impact on his private life, professional and economic.(154)

In Spain, circa 1986 started a boom in medical claims, which created the "Defensive medicine"; however, there are many factors interacting with each other have increased litigiousness. The trend is that in practice defensive medicine will increase, said that, in the US for 2000 the cost of claims ranged in 41,000 million dollars, then in 2008 the cost was 200,000 million per year, representing 10% of total health spending for the nation. Most medical claims are related to the information given to the patient and family and rarely with the effectiveness of medical practice, hence the importance of "Informed Consent " and the development of good and effective relationship doctor-patient including family members responsible for the case.

SUSCEPTIBILITY TO MEDICAL ERRORS IN INTENSIVE CARE UNIT (ICU).

"The smart man learns from his own mistakes, the wise learn from the mistakes of others." Adasme Arturo Vasquez.

The Institute of Medicine of the United States (IOM) in 1999, published an article entitled: "To err is human", estimating that medical errors were causing between 44,000 to 98,000 deaths per year and determined that the Intensive Care Unit (ICU ) represented a substantial part in terms of challenges in patient safety. The work within the ICU, is a special feature highly complex and usually requires urgent high-risk decisions in a short time, including treating individuals whose personal details and anamnestic are unknown or poorly provided by individuals or families, in addition to this, patient must be addressed by doctors at various levels of training in critical care or are interconsulted specialists. The error in the medical indications, is associated with a high proportion of incidents and adverse events, the drugs most often associated with errors in ICU are cardiovascular drugs (24%), anticoagulants (20%) and antibiotics (13%), and usually they occur during procedures or administration of treatment (74.8%), especially by the medical order or interpretation thereof. In general, within the critical care units, drug specifically relate to error are: inotropic, narcotics, sedatives, analgesics, magnesium, anticoagulants and antibiotics.

ICU personnel should recognize their limitations in dealing with certain diseases or complications that are not properly prepared, and the physician must advise the patient of it, their families or representatives to present options; interconsultation as other specialists to strengthen the diagnosis and behavior. To specific complications can be timely patient transfer to a specialized center or with better resources. The principles of ethics, autonomy, beneficence and justice must be key elements that underpin clinical making many of its decisions in ICUs. (155)

MISTAKES IN CRITICALLY ILL ADULTS

In industrialized countries, in order to optimize the quality of health service delivery and minimize the possibility of errors, especially in the treatment of critically ill adult patients, a review of the scientific literature was conducted between the years 1985 - 2008 , mistakes made by nurses of Intensive Care Units (ICU) reported on the leaves of patient records, where it was evident that they were bound by medical indications with a variety of drugs at different doses is considered a same patient, which was a factor error added to misguided treatments. In the ICU great clinical skills it is needed, and a correct and meticulous way of working because of the complexity operating within these structures health, since it works with patients prognosis and highly susceptible to serious consequences when committed mistakes. (156)

Errors in medical indications, especially in treatment, were defined as preventable prescription or improper use of a drug that has caused damage. Generally ICU nurse can make mistakes during drug delivery, as well as error in the calculation and preparation of doses, antibiotics most frequently involved are amikacin, vancomycin, metronidazole and ciprofloxacin.

As cardiovascular drugs related mistakes are indicated: digoxin, epinephrine and also electrolytes such as potassium and magnesium. Among the factors frequently involved distractions nurses are identified, deficiency in communication nurse versus doctor. It is worth noting they also constitute errors, lack of stability and bioavailability of various drugs, which can cause drug overdose often, opioids can cause severe respiratory depression in spontaneously breathing patients and not significantly affect a patient under mechanical ventilation. (157)

THE NEUROLOGICAL EMERGENCIES

"The man rushes into the error faster than the rivers run into the sea." Voltaire.

A significant portion of patients presenting to the emergency department with neurological symptoms, and in this context, the most common symptoms are headache, back pain, drowsiness and seizures. Then we highlight that in relation to headaches, they constitute about 2% of visits to emergency rooms. They have shown the diagnostic failures subarachnoid hemorrhage from 12 to 25%, which are probably related to the variety of clinical presentations, not following an "algorithm work" not understand the limitation of scales and neurological diagnostic tests and also ; because not all patients with subarachnoid hemorrhage have a sharp picture with headache, and in some people the headache improves with painkillers. (158)

Among other reasons for neurological consultation that can lead to errors described:

Back pain. Among the most common etiologies are ponytail compression, disc herniation, tumors, abscesses and hematomas. For proper diagnosis along with a good history and a thorough physical examination, Nuclear Magnetic Resonance (NMR) is needed. The cauda equina syndrome may be misdiagnosed when there is an incomplete medical history, physical examination errors in communication between doctors or between doctors and nursing staff. (159)

Drowsiness, is another reason to consult the neurological emergency; when an individual comes showing widespread sleepiness, you may have some toxic-metabolic problems ranging from electrolyte abnormalities, dehydration, medication side effects or systemic infections. Less common causes include drowsiness generalized Guillain Barré syndrome, an autoimmune disorder of unknown etiology and that usually occurs in adults 30 to 50 years; transverse myelitis neurological condition due to an inflammatory process of the white matter of the spinal cord, which can cause axonal demyelination; myasthenia gravis is also mentioned, a disease characterized by a pathological muscle weakness or fatigue caused by an autoimmune disorder; periodic paralysis (rare hereditary condition that causes progressive muscle weakness episodes whose two most common types are hypercalcemic and hypocalcemic); and botulism poisoning or bacterial neurotoxin produced by Clostridium botulinum (the most common route of poisoning is food). (160)

Dizziness. As well as headache, dizziness is another condition that can have from a benign to a very serious connotation, and this can make it difficult to distinguish; one element that affects the error of interpretation is the use by patients inadequate to describe their own symptoms words. In the case of sickness, the patient usually use the word "vertigo" or "revolving feeling" that are not useful to identify the picture. There is a fine line between mistake, such as a vestibular neuritis and labyrinthitis a cerebellar stroke or brain stem. Similarly, poor or inadequate physical examination as a wrong medical history leading to a misguided diagnosis. (161)

SAFETY, FAULTS AND ANESTHESIA.

latent conditions

"That they call truth is merely the elimination of errors." Georges Clemenceau.

The safe handling of anesthetic drugs has improved due to the advent of more reliable and safer drugs, as well as the existence of good quality equipment; but the use of polypharmacy, complex working conditions involving multiple medical and paramedical training standards in this area can be exposed to a medication error somewhere along the anesthetic procedure. Most of these errors can lead to high mortality and morbidity by prolonging hospital stay, the high cost of treatment and litigation. (162)

The Japanese Society of Anesthesiology (SJA), investigated 27 454 anesthetic procedures in a period of eight years (1999-2007) and found a total of 233 medical errors where overdose, drug substitution and omission of anesthetic drugs were present.(163)

Errors in the administration of the anesthetic medication

The anesthetic medication errors are divided into two groups according to the system of active and latent conditions job fails. Is considered "active fault" unsafe acts committed by anesthesiologists who are in direct contact with the patient due to errors in prescribing, judgment, inference and interpretation; whereas "latent conditions" mean that individuals within the health care system, make decisions with consequences not well considered in the future, for example: don´t anticipate side effects or after-effects that patients suffer. Alternatively errors fall into errors of omission and errors of commission. (164)

In anesthesia most critical accidents occur during induction (42%), and the beginning of the procedure (17%), also errors occur during the administration of medication 53%, followed by prescription 17%, and preparation transcription 11%.

It is believed that human error is a factor responsible for 65 to 87% of deaths during anesthesia, the drugs often related to medical error in the practice of anesthesia are inducing agents such as sodium pentothal, ketamine, relaxing muscle, narcotics, sedatives generally anticholinergic, local anesthetics (due to misidentification; labeling error, wrong syringe exchange with other drugs or medication.) (165)

Anesthesiologists are one of the few groups of physicians are personally responsible for the administration of a drug, during anesthesia most mistakes are totally or partially attributed to human error and inherent part of human psychology activity and therefore the occurrence of this can only be reduced, but not eliminated.

PREVENT MEDICAL ERRORS IN SURGERY

For decades the medical personal of surgical teams, has resorted to manually count sponges, needles, scissors, retractors for the opening of anatomical sites and other gadgets used during the operations before the end of the surgical procedure, sometimes more than one hundred, used computers that are recorded, for this reason, the University of Michigan has devised sponges with bar codes , which is scanned twice, first when used during the intervention and the second when removed from the body. If there is discrepancy in the count, the surgeon knows that he has to look in the area of surgical gauze or missing instrument. According to experts, the gauzes are objects that most often are forgotten in the body after surgery. X-ray equipment used to find lost objects while the patient is still in the operating room, x-ray can identify metal and soft objects. In addition, these new sponges with bar code contain a label that is opaque to the radiation, allowing to be detected during an x-ray. The Cardiovascular Center at the University of Michigan and the C.S. Mott Children Hospital, part of the initiative to prevent forgetfulness of surgical items held within the human body, in such a way that there has been no incident of this kind last year; and the researchers hope to extend it to other hospitals. (166)

THE MEDICAL ERRORS IN Transfusional Medicine

In recent decades, the health services of developed countries have devoted many resources to improve the biosecurity of blood for transfusion, the "transfusion chain" that goes from the donor to recipient through transfusion Blood Bank is safe and regulated, so that infection transmitted through a blood as globular concentrate, whole blood, fresh frozen plasma, cryoprecipitate, platelet concentrate. (167)

HAEMOVIGILANCE SYSTEMS

Within systems hemovigilance the SHOT (Serious Hazards of Transfusion) stands out, it's a control system transfusions using the UK requesting communication or report side serious adverse transfusion, including cases of "transfusion an incorrect blood component "(TCSI) where transfusion of a blood component that does not meet the specific needs or should be given to another patient is performed. (168)

Since 2000, also there have been "borderline incidents" in which an error was detected prior to blood transfusion, thus, important indicators of situations, which could appear an adverse outcome were obtained.

There are weak links in the chain of transfusion as decisions are often the justification for a transfusion errors in the application and prescription. These errors are due to a faulty or poorly documented the results of laboratory tests interpretation. The decision to prescribe a transfusion must be based on the existence of clinical signs and symptoms supported by laboratory results. If the results of laboratory tests do not correspond with the clinical picture of the patient, we must be very careful, because if they are wrong, they can have their origin in inadequate or errors in analytical samples. (169)

Likewise, the reports given by telephone may be susceptible to error and may refer to a different patient. Adverse events may also have originated from the doctor failed to provide essential information to the laboratory with respect to patient transfusion history or special needs (previous detection of alloantibodies or indication to irradiate blood components). (170)

Errors in the taking of samples, can be produced by labeling test tubes with samples away from the bed of the patient and the patient's identity is not checked, samples for diagnostic investigations cause sometimes inappropriate transfusions can have serious consequences . To reduce the risk of errors in sampling, the staff in charge of drawing blood, must be properly trained and if possible, evaluated. (171)

Lab errors in Blood Bank generally occur due to manual techniques urgent blood group determinations are themselves, and unsafe, and are associated with errors of interpretation and documentation. Unless the Blood Bank Service count fully staffed 24 hours a day, applications for transfusion at night should be limited only to those patients clinically justified.

There are basically two types of situations that may arise during indication of a blood component, and they are:

a) Failed component management

It is one episode in which a patient is transfused blood component that does not meet the appropriate requirements or was intended for another patient.

b) Incident void or "near misses"

Any mistake, that failure had been detected in time an incident in the transfusion process, but which when detected before transfusion, is avoided.

Serious medical errors in transfusion medicine

Severity 0: No clinical manifestations

Severity 1: Immediate signs without vital risk and full resolution of the condition.

Severity 2: Immediate signs with vital risk

Severity 3: Long-term morbidity

Severity 4: Death of patient

No data: No record data on gravity or have not been able to gather.

POST-TRANSFUSION immunological reactions

Reaction | Immune | Non immunologic

---|---|---

Immediate | • Immediate Hemolysis

• Anaphylaxis

• Hives

• Febrile reaction

Acute lung injury | Bacterial Contamination

• Hemolysis not immune

• Overload citrate

• Volume overload

• Overload potassium

Delayed |   * Delayed hemolysis

  * Post-transfusion purpura

  * Graft versus host reaction

  * Immunomodulation
 |   * Transmission

of infections

  * Hemosiderosis

Taken from: (101)

CAUSES OF TRANSFUSIONAL ERROR

1) Failure to carry out informed consent

2) Authorization blood of a different group ABO or RH patient

3) Authorization of blood that is not properly registered

4) Lack of recognition of the adverse effects of blood transfusion

5) Bad heating techniques of blood products, (use of microwave ovens or direct heat above 41°C.)

6) No transfused within the first 4 hours (pollution occurs by bacterial growth)

7) Use of blood without the patient meets the criteria

8) Mishandling of fluids and blood products to susceptible patients (cases of patients with heart failure)

9) No patient monitoring during transfusion.

10) Approval and implementation of blood products met expiration date (expired).

11) Do not consider underlying conditions of the patient.

HIV-1, HIV-2, HCV, HBV, HAV, parvovirus B19, CMV, HTLV-I, HTLV-II, V. Epstein Barr, V. 13) Inside accidents transmission of diseases like virus are relevant Hepatitis E, Hepatitis Delta; bacterial infections Yersinia, Treponema pallidum (syphilis), Plasmodium malariae, Trypanosoma cruzi, among others. (101)

STATEMENT OF CLAIMS AGAINST MEDICAL STAFF

Among the most frequent causes of medical complaints of delays in care for the sick, and errors in diagnosis, the fatal consequences of performing diagnostic and therapeutic procedures, application of wrong behaviors or incomplete treatments mentioned (partial tumor resection). In the United States (US), it is almost a custom sue for medical malpractice for various reasons such as high fees charged by doctors, the loss of the doctor-patient relationship, the existence of malpractice insurance and attitude lawyers. (172)

TRIAL AND MEDICAL LEGAL ALLEGATIONS

"Fiat iustitia et ruat caelum". Latin aphorism

Today, the patient is aware that he can sue the doctor if you are not happy or satisfied with the result, patients are demanding more humane care while specialists complain of lack of time and resources. The "trial industry" in the health field, far from diminishing advancing at a dizzying pace that is good for nothing but smother the moral and economic health system of a country. In Spain, 50,000 annual malpractice complaints are recorded, according to the Patient Ombudsman, 60% more than 10 years ago.

There are times when the doctor often confronted with the dilemma of what to do for the good of the patient, and what the likely actions is more favorable and less damaging to it, obeying the principles of respect for the sick, human integrity , preservation of health and of course the law. However, health professionals are subject to unpleasant situations represented by civil, administrative or criminal charges in error or malpractice. For this and much more, really tarnishes the legal medical practice and in many cases unjustified errors that are ignored; and threatening the integrity and life of the patient which consequently causes damage. (173)

The exercise of medical practice should be assumed responsibilities in building ethical values and professional and institutional commitment.

In developed countries, despite the great technology doctors say, which is often compelled to follow the patient to unnecessary and unjustified initiate further studies, fearing to face a possible lawsuit. Sometimes doctors can fall into the paranoia and even get to see patients and their representatives as enemies given the existence of a potential conflict, which further deteriorates the doctor-patient relationship. (174)

MEDICAL narcissism. The DOCTOR´S dangerous ego

The narcissistic personality disorder is defined by the manual of psychiatry DSM-IV as an immense sense of self-importance, requiring excessive admiration and lack of empathy, analyzing this maybe the medicine would be the "ideal job" for the satisfaction narcissist. The narcissist suffers from low self-esteem, but like to draw attention to counter their sense of inferiority, its prevalence is higher in men than in women, which include feelings of grandiosity, superiority, egoism and who think only of themselves. The extreme form of narcissism is called "perverse narcissism" which consists of the satisfaction of wants and needs at the expense of the other. (175)

There are doctors who take risks, more to demonstrate their expertise by a real need of the patient, they may be pressured by commercial, corporate and labor issues saturation. The doctor narcissism is characterized by focus more on the disease in the patient. One doctor-patient relationship where the first control everything in order to avoid anxiety and discomfort as a mechanism of self-protection is established. The most typical features of medical narcissism are feelings of superiority, authority, perfection, self-admiration and arrogance. (176)

The boundary between "healthy" narcissism and "pathological" would be a healthy self-esteem, while pathological narcissism would be arrogant attitude of "smarty" and have total control, the doctor never hesitates or shows his mistakes and fears and always it acts as if everything was fine. (177)

Within the psychological dynamics of narcissism, the "I" is idealized, even by patients who see a doctor as a powerful healer. While the patient is often reduced to a number of "bed" or a "history" virtually disappears as a person.

The doctor-patient relationship in these cases becomes asymmetric, narcissism interferes with the doctor-patient relationship, the doctor is the almighty and the patient is weak. The word "sick" comes from the Latin "in firmus" which means "to be weak", and when individuals lose their north in relation to the other and it is thought that the most important is what corresponds to the "I" is impossible to establish an adequate bond; as the "other" (in this case the patient) is the basis of moral existence. If the other is not considered as a person, as an individual and as a human, our moral disappears; meanwhile, scientific medicine tends to treat human necessarily measurable object while transforming it into an object, medicine is dehumanized. (178)

You should look for changes in the healthcare system and proposals in the academic sector to avoid narcissism. It is shown, that is precisely the lack of communication between doctor and patient or family, the reason for over 95% of applications in the medical field. (179)

Also, easy access to information which today have patients and users of the health system either over the Internet or the press does not help to balance the doctor-patient relationship, if it is true that patients can provide information this can be dangerous in the long run because they can even come to believe by their own narcissism, which are able to replace the doctor.

LUCIFER EFFECT. THE GOOD AND BAD DOCTORS

Inside the mind and acting of human beings, we have the "free will", which gives us the power to decide between doing good or evil. It has been investigated how the placing people in place can adversely affect their behavior, because the environment can eventually change the way we behave. The individual carries cultural qualities, psychological and individual and own intellectual that characterize and differentiate them from others. Immersed within a complex social structure, full of social and economic demands as well as temptations and difficulties, their behavior often must "fit" within certain conventions. (180)

In this sense, the work of Professor Philip Zimbardo, which was written in 2008 entitled whose fundamental thesis "The Lucifer Effect" is the theory of "how good people can become in bad people" outlined Professor Zimbardo tried to discover the origin of the evil, based on his long personal and professional experience as a social psychologist, taking for this experiment Stanford Prison by behavioral observation of prisoners and jailers. In this experiment, he examined several triggers of evil, as the "blind obedience to authority" (abuses of teachers, parents and all those who exercise power), determined that it can placate or demoralize someone with words and identified as anonymous, he plays a crucial role in the harmful conduct and protecting the identity of the sadistic individual acting as a mask, and this; you feel free, powerful and protected to act and continue their work. The "seed of evil" takes place in our brains when we dehumanize, we attack or not we avoid that a heinous act, a crime punishable committed or something and it seems that is anatomically located in the limbic area of the brain. Some people do not test well with whom they associate, and when people commit reprehensible acts regardless of their future consequences thinking only of the present danger to repeat these actions run.

Zimbardo´s written by one of the points made is conclusive modify or withdraw the objectionable conduct by a group of people or requires factors such as strength, determination, virtue and vulnerability that contribute to a given situation also signals the loss of the sense of individuality subjects suffering when they are immersed in certain social groups that stigmatize, hauling result in a change in behavior, can a blind and irrational obedience to authority occur, passivity against the threat higher or others, self-righteousness by which the individual is convinced that he is right, but what you are doing is considered an outburst in the eyes of humanity itself. Rationalization, defense mechanism is to justify the actions (usually themselves) in order to avoid censorship trying to give a "logical explanation" to the feelings, thoughts or behaviors that otherwise would cause anxiety attacks, inferiority or guilt. Before a despotic, cruel, unhealthy, the best person in the world authoritarian environment; you can become a murderer. Described above can happen to the doctor or health team when an error, iatrogenic or malpractice is committed and is justifying evade responsibility, hence the similarity with the thesis developed in "The Lucifer Effect". (181)

Given the disturbing transformation of the behavior in the "good" to "bad people" people considered, Professor Zimbardo suggests a possible antidote the heroism.

Worth mentioning, that medicine is a discipline that necessarily uses human interaction, today is the critical and even it has been discredited by its tendency to mercantilism and dehumanization. Given these strong criticism, he tries to rescue his good image based on the fundamental pillars of a "medical heroism" in order to put a limit to the ruthless and often, unfair attacks. This campaign for the virtuous and ideal medical practice exercise is supposed collaborate in the significant decrease of bad medicine. (182)

The profile of this man, virtuous and heroic doctor, should include the ability to self-analysis, concern for acquiring a high level of professional training, great responsibility, selflessness and sense of duty, ability to overcome your own ego for the benefit of health patient humbly recognize the limitations of their field of action, promote and require the authorities to regular and systematic implementation of panel discussions of cases of errors, iatrogenic, dyspraxia and medical malpractice, seeking to amend faults and optimize the medical act avoid being punitive or slanderous and promoting education aimed at updating treatments and constant observation and reminder ethical considerations and the laws governing the conduct and daily work of medical professional.

OmertÁ POLICY IN THE HEALTH CENTERS:

"When silence is imposed as a duty"

The "omertá" or "law of silence" is an Italian term of uncertain origin, dating back from 1800 whose origin is related to the Latin word humilitas (humility), which would be modified by dialectally "umirtá". Omertá is a code of honor in ancient Sicilian mafia that prevents give information on the activities of the organization or staff of the same to third parties. The violation of this principle is punishable by death, including reprisals are less burdensome extortion, blackmail, threats to the family, and damage the reputation and career; The spanish proverb says: "The dirty laundry is washed at home". (183)

The pacts of silence well be explicit or tacit exist in many organizations and the health sector is no exception to this, often they serve to cover up crimes and criminals. Those subject to "pacts of silence" do not often see, hear or say anything, omertá is essential for companies with illegal or unethical activities; so that maintaining the secrecy of the proceedings prevent public opinion, civil or criminal justice interfere.(184)

DISCUSSION OF MEDICAL ERRORS AND ADVERSE EVENTS

"The error is a weapon that always ends up fired against which employs". Concepción Arenal.

In medicine incorporating the recognition of medical errors it has been slow, as it encompasses both health professionals and the public and private systems. In some countries like the US, conferences impact on morbidity and mortality caused by medical errors are made. (185)

Consequently, discussing errors is a goal to learn from them and prevent them openly comment on the occurrence of errors can be more alert and provide better quality health care, and provide patient satisfaction. Similarly, the existence of failures in the health system must be improved or corrected.(186)

Should DOCTORS DISCUSS THE ERROR WITH THE PATIENT ?

There are many factors that can inhibit the medical professional to report a medical error ranging from fear, fear of damaging their reputation and many other situations that may be uncomfortable. However, reveal an error and take appropriate measures may prevent continue to commit, and conversely, to hide the fact, deterioration of trust between doctor and patient and exacerbates their commission. (187)

Then point out some attitudes of both physicians and patients according to Gallagher, Garbutt and Waterman, which identified three areas 1) What are the attitudes of patients in relation to the commission of errors by doctors ?. 2) Should doctors discuss with patients or reveal committing an error? 3) What are the emotional needs of patients and physicians when a medical error occurs and what should be the solutions to be found? (188)

Comparison of the different attitudes of physicians and patients regarding a medical error

Issues or focus group discussion | Attitudes of patients | Attitudes of physicians

---|---|---

Definition error | Not discuss preventable adverse events, deviations in health care, poor quality of service and poor interpersonal relationship of doctors. Open attitude. | Closed attitude is accepted only discuss deviations from the standard of care.

What mistakes should be disclosed to the patient? | Reveal all errors that cause damage. | Reveal errors that cause harm, unless it is a trivial or irrelevant damage that may create more problems than benefits

Speaking in relation to forgetfulness | Mixed positions. | Should not be discussed on medical forgetfulness

What information should be disclosed with respect to medical error? | It must reveal all | Should carefully chosen words to use

How disclose medical error | Tell the truth and show compassion

 | Tell the truth, be objective and professional

Apologize | It is recommended to apologize | Believe that apologizing can make a legal sanction attributable

Emotional impact of the error | Shock, anger, frustration and emotional imbalance | Frustration. I desire to understand the damage and its impact

Source: Modified our (113)

Patients generally agree that they would like to know those errors that cause harm, they want to know how and why it happened, the implications for their health, how it can be corrected the problem and its prevention in the future. Although patients want to quickly find medical errors, they accept that sometimes come to obtain information on the error cause and prevention can take time.

From the psychological point of view patients describe a wide range of emotional responses after a medical error such as sadness, anxiety, depression, trauma, anger, annoyance; for his hospital stay is prolonged and frustration because the error could have been prevented. However, physicians also experience strong emotions after a medical error, they feel responsible for having caused harm to the patient, and develop feelings of guilt that affect their emotional, work and private life, present fear of a possible lawsuit and anxiety what all this might affect his honor and reputation. (189)

Medical errors are unfortunately unavoidable part within the medical practice, and patients want to know the details, causes, consequences and prevention of them in the future. There is a very stressful time that starts from the commission of the error, until the moment when he must speak of it to a patient and which can give rise to any dispute. (190)

WHAT NOT TO SAY OR DO BEFORE A MEDICAL ERROR

"There are no frontiers for medical passport is universal, and no expiration has only one nationality, humanity "Juan Francisco Jimenez Borreguero

There are situations in medical malpractice lawsuits that may precipitate and within the array of behaviors that are considered very harmful, are the prematurely happened not admit fault or apologize not speculate or justified. They should not offer conjecture; while not know the whole truth.

We must remember that in these situations it is important to use calm and proper body language, doctor should find a quiet place away from noise and distractions, turn off the phone when you need to convey news of great importance also should also allow family seated, explain what happened into his eyes, speaking slowly and honestly, you should avoid using the word "okay". Sometimes it demonstrates empathy is more convenient to use the language, take the hand of someone crying, give a hug or just listen can help.

Nurses are the staff who are literally forced to interact with aggressive family in the day, therefore, the staff should also be trained to maintain empathy. In an unexpected situation adequate nursing staff response should be: "I know you are upset Mrs. Smith again how sorry that this happened, which tells us seek review of medical records and nursing.. Currently, is there anything I can do for you or your family. "? (191)

THE TRIAL AGAINST THE LEGAL MEDICAL ERROR

Currently due to multiple factors, the patient has acquired the knowledge that before an unsatisfactory result, can sue the doctor, probably to sue patients are demanding more humane care. The so-called "trial industry" within the health field far from diminishing advancing at a rapid pace, which ultimately only serves to stifle the economy and moral health system of a country. In recent years in Spain they have counted more than 50,000 complaints a year for medical malpractice according to data obtained from the records of the Patient Ombudsman, 60% more than 10 years ago. In developed countries, despite the great technology that doctors say is often forced to make unnecessary follow patients and initiate unjustified, required additional studies for fear of facing a lawsuit alleged. Sometimes doctors can fall into paranoia and even get to see patients as enemies given the existence of a potential conflict, which consequently could further deteriorate the patient-physician relationship. One of the most serious medical consequences to commit malpractice are the lawsuits. In Venezuela, personal injuries are contained in the Criminal Code "crimes against persons", within it, Chapters I and II relate to "Personal Injury" Articles 411 to 422 specify what they are about, and points penalties when they are violated.(192)

The legal order that establishes the criminal protection of the people, is the need to protect life. The right to life is a universal human right, recognized by everyone and no one can make arbitrary use of it, or injure; the right to life is also considered in the Constitution of the Bolivarian Republic of Venezuela 1999 as an inviolable right. We must remember that among the general rights and duties of doctors is the respect for life, dignity and integrity of the human person as a primary objective. So that when committing a mistake, there is no intention to kill or cause harm to the patient, therefore, the vast majority of these errors fall into intentional crimes.

Let us briefly discuss some of these articles of the Venezuelan Criminal Code to better understand their scope:

Article 411. "He who for having acted with recklessness or negligence, or with inexperience in his profession, art or industry, or for breaching regulations, orders or instructions, caused the death of any person, shall be punished imprisonment of six months to five years. In the application of this penalty the courts appreciate the degree of culpability of the agent. "Close quote.

We observed that in this type of murder, there is no intention to kill, or even hurt the taxpayer; however the perpetrator, in this case the doctor should have foreseen the harmful outcome as a result of his unlawful act or omission. So, recklessness, refers to a lack of prudence, caution or precaution, it is one of the characteristic elements of intentional crimes or negligent injury; it is incurred by action or omission; although the omission seems to fit more to negligence. Consequently, whoever commits a crime by negligence, shall incur criminal liability and the obligation to repair the damage. The same obligation to compensate the civil law establishes who cause damage by negligence, without incurring penal sanctions falls under the category of tort. (193)

Negligence: Negligence or fault in omitendo, is part of the conditions for the crimes of culpable nature occur, is an abstention, a "do"; an omission when he was legally obliged to do the opposite behavior. It is an omission, more or less voluntary, but aware of the diligence corresponding to the legal acts on personal ties and custody or asset management. (194)

The last paragraph of the standard, foresees the aggravation of sentence when the fact is the death of several people along with injuries to another or others, as long as these are of a serious nature (mental or physical illness, certainly or probably incurable, loss in some sense, a hand or a foot, speech, the ability to generate or use of an organ, or a wound that disfigures or committed against a pregnant woman with abortion accordingly.) (195)

Vicarious negligence: This term applies when certain exclusive professional tasks are transferred to another and the result is not satisfactory. For example: a doctor, trusted colleague, leaving the hospitalization area, in the certainty of punctuality on the other; what is not verified. Consequently, a patient is damaged by the absence of professional in one workplace. Ethically speaking both are considered violators of the rule. The same can not be said when a doctor is replaced by another colleague at his request and it acts negligently; it would be unfair that the first doctor responded by neglect of the other, when it should treat the patient carefully. Regarding the field of criminal liability is strictly personal. (196)

Malpractice. The inexperience is the lack of experience, quality or skill in the exercise of a profession, occupation or art. For some authors, inexperience is a professional fault. Along with the negligence and recklessness are the triad why, or independently in each of the figures the offense of culpable nature is formed.

Failure is the lack of observation, execution and detailed compliance with an order, a duty, lack of respect and submission to a higher, a failure to proceed in accordance with pre-established rules, those written instructions to govern an institution, to organize service or activity; It is the methodical and provision of some length on a subject in the absence of law or administrative power dictates contemplate. According to the authority that promulgates it is facing a norm with certain authority.

Intentional crimes. The intent, in the legal sense corresponds to the intention of causing harm. In terms of health it corresponds to the acting physician, knowing that violates a law, performs the act in the same way. A classic example is performing abortions in a country where it is penalized.

Unforeseeable circumstances. It is defined as the damage caused by an intervention, properly indicated, but that is completely unpredictable, often being secondary to own body's metabolic processes. One example would be malignant hyperthermia subsequent to the administration of a general anesthesia for surgery.

In the opinion of Venezuelan lawyer Dr. Alberto Arteaga S. the medical profession opinion has exaggerated the protection of its members, systematically denying any reference to alleged cases of medical error, negligence or recklessness in the exercise of the profession; meanwhile the media, echoing complaints and opinions from various sectors have often promoted campaigns generalized discredit against the medical profession or medical groups, it has even contributed to hindering the investigation of crimes committed by true professionals medicine. This occurs in the context of a Venezuelan criminal justice that is slow, archaic and limited to certain cases and people; and media whose opinions in the criminal field often become supreme judges, prosecutors and defenders in "certain cases" forgetting the important role that could meet to collaborate with justice and serve the public controllers of legality the best interests of the community. (196,197)

In the same vein liability, binds the physician to respond with their heritage and that this obligation is economic in nature and may be of reparation, restitution or compensation. In some countries, the discussion of civil responsibility has become a serious problem that interferes with the free play of doctors. The proliferation of claims for compensation, has forced medical professionals to recruit insurance premiums to protect their own assets costly situation that paradoxically, increases the costs of medical services to the general population, and in the end, these premiums end up being transferred to users through the cost of medical fees. (198)

Hence the liability is the obligation of a person to repair the damage caused by his act or that of a person under their care. Article 1185 of the Venezuelan Civil Code quote: "Anyone who intentionally or negligently or recklessly caused damage to another is obliged to repair it." This means that there is no damage liability, and this applies to both contractual and the contractual field. The damage requires some requirements the judge must have evidence that the victim be better off if the agent had not realized the fact. The damage must not have been repaired, since there is no action without interest, it should affect an acquired right and must be personal. For its part, the blame has tried to define as an illicit act attributable to the author, including two key elements; wrongfulness referred to damage without law and accountability, so that if the act is attributable to its author, will fall into causation. The fault is defined as an error of conduct, so that you can be sure that on that error would not have incurred a prudent and diligent person, to the same external circumstances. (198)

COMPENSATION DUE TO ERRORS

The various undesirable situations that may arise in the development of the practice of medicine and can cause errors compensation, as required by the physician behavior to empathize and conduct a thorough review of errors for Demosthenes that was the case, the patient you will need an apology and probably also cover financial needs. Demosthenes is due to the patient and family, how will avoid in the future that mistake will not happen again, you may be drawn up a letter of apology or seek ways to honor the memory of the patient. Likewise, if there is a lawsuit, one of the things that patients or their relatives should require will be the economic recovery of damages suffered as well as disqualification from the exercise of medical and moral damage caused. (199)

How to deal with medical malpractice

Before filing a lawsuit, you must collect evidence in order to document the record, and the data that prove that there was indeed committed medical malpractice, we recommend the advice of a lawyer specializing in this area, and in turn collaboration a medical specialist the damage expert to confirm that the patient was the victim of neglect. The lawyer will guide compensation and will implement procedures to give effect to the claim, may be held responsible by any damage caused criminal, civil and administrative. In cases of death or serious injury, it is advisable to go to the criminal courts because they can expeditiously achieve what the subject intends. By bringing the case, it is important to be certain which is directly responsible medical fact, because it is an error reporting an entire medical team, however; you should always demand along with the doctor, as jointly and severally liable to the clinic or hospital to ensure that the judgment becomes effective if the doctor does not respond. (200)

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 infarction, neurological defects, loss of function or mobility of a body part, partial paralysis or general (motor), brain damage, damage to the spine, loss of feeling in any part of the body, coma and even death.

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 about their errors with colleagues; 70% believed that discuss errors strengthened professional relationships and most knew at least one colleague who would be a supportive listener. Among the motivations for discussion error was the concern of whether another colleague would have made the same decision (91%), learning from the mistakes of colleagues 80%; and desire to receive 79% support.

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 are avoided; not least the remaining 21% consisted of gaps in terms of specialized medical and paramedical staff as well as poorly equipped laboratories, radiology and radiotherapy. This complaint, as constant variable both in the survey and in interviews, does reflect on the need of the patient journey of a health center to another, which contributes to the deterioration of the doctor-patient relationship and your health condition.

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 the symptoms of emotional exhaustion at the doctor.

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 the activity of a particular craft or trade and for the effects that the acts occur in accordance with the regulatory system, it shall cause a civil or primarily criminal liability. (4) If the focus belongs to the criminal field orientation will be toward medical malpractice and enter to discern if it was an unlawful act and the connotation of guilt. (8)

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, complications and everything related to the patient are useful while diagnosing faults and assign responsibilities. Another tricky part related to medical mistakes is that even in studies and cardiovascular tests quality eco interpretation can vary widely depending on the doctor. In some hospitals in the US there is a computerized medical records system that discussed in detail especially those patients in whom complications occurred and where data ranging from the names of the doctors involved, procedures, duration of illness, hospitalization specified , type of treatment, drugs and doses mentioned, evolution and thanks to this system has been made even divest certain doctors in hospitals.

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 form way to the operating room, on the contrary, the language must be accessible (principle of adequate information); as this can be an instrument of defense against the allegation of malpractice, it is to sense a greater dignity of the person. Consent is not a irrevocable and permanent (principle of reversibility and temporality) act. It notes that the fact of having informed consent, by itself, does not exempt from responsibility to the doctor when there are other faults in fulfilling the duties of conduct. (62,66,171)

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, written, organized as a complete census in order to avoid errors and delays colleagues.

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.

