Análisis de las quejas derivadas de las prácticas quirúrgicas / Complaint analysis derived from surgical practice

Se analizan los asuntos presentados ante la Comisión Nacional de Arbitraje Médico desde junio de 1996 hasta diciembre de 2007, para difundir su magnitud e identificar los problemas de seguridad en la atención médica. De 182 407 asuntos, 87 % lo resolvió el Área de Orientación y Gestión. Las restantes 18 443 quejas fueron derivadas a la Dirección de Conciliación; de ellas, en 48 % se logró la conciliación entre promoventes y médicos y en 31 % esto no fue factible; 3 % se trató de quejas irresolubles. La mayor frecuencia de quejas se registró en el Distrito Federal y Estado de México, principalmente correspondientes a instituciones de seguridad social y hospitales privados. Entre las nueve especialidades involucradas con mayor frecuencia, existieron seis quirúrgicas. Se identificó mala práctica en 25 % de los casos. Las principales pretensiones de los promoventes de las quejas fueron reintegro de los gastos erogados por atención médica en 51 % de los casos e indemnización en 40 %; en estos últimos el monto promedio de lo pagado por caso fue 4.6 veces mayor. El conocimiento de las quejas médicas permite investigar sus causas y generar acciones preventivas y correctivas, para su abatimiento. Se propone que la Academia Mexicana de Cirugía, por su liderazgo académico y docente, asuma la vanguardia en la difusión y promoción del plan “Las prácticas quirúrgicas seguras salvan vidas”, de la Organización Mundial de la Salud, y la implantación en nuestro país de la “Lista de verificación de la seguridad quirúrgica”.

This study reports on the analysis of medical complaints presented to the National Commission on Medical Arbitration (Comisión Nacional de Arbitraje Médico, CONAMED) between June 1996 and December 2007 to determine its magnitude and to identify the causes of safety problems in medical care. Out of 182,407 complaints presented to CONAMED, 87% were resolved by the Office of Orientation and Management. The remaining 18,443 complaints were presented to the Council Directorate. Of those cases, 48% were resolved by an agreement between the complainants and the physicians, 31% were not resolved by this method, and 3% were irresolute complaints. The highest frequency of complaints was registered in the Federal District (Distrito Federal) and the State of México (Estado de México), mainly corresponding to social security institutions and private hospitals. Among the nine most frequently involved specialties, six were surgical specialties. Malpractice was identified in 25% of all cases. The principal demands of those making complaints were the refunding of expenses in patient medical care (51%) and indemnification (40%) and, in those, the average amount of payments was 4.6 times greater. Due to the incidence of medical complaints, it was reasonable to investigate the causes and to take preventive and corrective actions required for its decrease. It was proposed to the Mexican Academy of Surgery that this organization should use their educational leadership and assume the vanguard in the dissemination and promotion of the WHO plan "Safe Surgery Saves Lives" and the implementation in Mexico of the "Surgical Safety Checklist."

Sistema ISO 9000 o evaluación de la calidad de la atención médica / ISO System 9000 or evaluation of the quality of medical care

Evaluation of the quality of medical care began in Mexico in 1956. This was done by reviewing the clinical files of patients. In 1984, Donabedian introduced the Theory of Systems that evaluates structure, process and results, adopted as a base in the IMSS to develop the System of Integral Evaluation and Continuous Improvement of the Quality of the Medical Care, through the identification and solution of the problems that affect quality in medical care as well as the improvements of the inefficient processes or those with low quality. The Joint Commission on Accreditation of Health Care, European Foundation for Quality Management (ETQM) and International Society for Quality in Health Care (ISQua) use a similar methodology in its evaluations. The ISO System (International Organization for Standardization) was created in 1947 to assure and to certify the quality of the production processes and to guarantee the quality of the products that were fabricated. In health institutions the ISO system is useful to certify the structure and organization, and it indicates that they are under conditions to assure the quality of medical care, but it does not guarantee that this must happen. On the other hand, faults in structure and organization may result in poor quality of care. We conclude that both systems are complementary, rather than exclusionary.

El error médico: eventos adversos / Medical error: adverse events

En la actualidad, la seguridad de los pacientes durante el proceso de atención médica ha alcanzado una relevancia prioritaria, determinando la necesidad urgente de garantizarles que sus necesidades de salud se vean satisfechas en las mejores condiciones posibles, sin verse complicadas por eventos adversos ocurridos durante el proceso de la atención. En el presente documento se proponen definiciones de los términos error médico, criterio médico, evento adverso y evento centinela, a fin de manejar conceptos semejantes. Se presenta la secuencia de eventos que puede conducir a la toma de una decisión correcta o incorrecta, el error consecuente y su derivación hacia un evento adverso, con daño para el paciente. Se hace énfasis en que la práctica médica está inmersa en un paradigma biológico impredecible, adaptativo, reactivo y creativo, a diferencia de las ciencias físico-matemáticas, que están dentro de un paradigma sujeto a leyes matemáticas, predecible y estructurado. Como consecuencia de esto, en la práctica médica cada paciente es una situación inédita que requiere de todos los conocimientos, habilidades y experiencias, para satisfacer sus necesidades de salud particulares, especialmente en situaciones críticas. Se proponen los medios para protegerse del error médico, incluyendo las guías clínicas, la medicina basada en evidencias, el mantenimiento de la competencia profesional a través de capacitación y actualización continuas, la relación médico-paciente estrecha, el estudio clínico completo y los registros escrupulosos en el expediente clínico. Como consecuencia de los errores médicos, con frecuencia se da lugar a eventos adversos que representan daño para la salud del paciente, o eventos centinela, que pueden tener consecuencias graves para la salud, la integridad o la vida del paciente. Se hace énfasis en que los eventos adversos pueden presentarse sin que esté de por medio un error médico, sino por fallas en la estructura y en los sistemas, incluyendo...

At the present time, care the patients safety during across the process of health is a priority target and determine the urgent necessity, to guarantee the satisfaction of their health needs, on best conditions as possible as it is, without complications for adverse events occurring in the medical attention. This paper purpose definition of different concepts like medical error, medical criteria, adverse and sentinel event, in order to define these concepts. Also try to show the sequence of events for a correct or incorrect medical decision, the consequent mistake and the possibility to produce an adverse event, with patient's damage. An important goal is that the medical practice is immersing in a biological paradigm, define like unpredictable, suitable, reactive and creative; very different to the exact science that has a predictable and structured paradigm, supported in mathematical rules. In the medical practice, each patient is an inedited situation and required all the knowledge, skills and experience in order to satisfy specific health needs, particularly in critical moments. The way for protect from the occurrence of medical error include the clinical practices guidelines, evidence-based medicine, the maintenance of professional competences by the continuous training, the close medical-patient relationship, integral approach of the illness and scrupulous data at the clinical record. In consequence, very often medical errors produce adverse events with damage of patients, or sentinel events with serious consequences of health, integrity or patient's life. Is important to say that the adverse events could be appear even without a medical error, just for failures in structural and systems issues, including resources and it's maintaining, organizational variables, communication, human resources, training programs, process without standardization, failures an supervision or control phases. This paper shows current adverse and sentinel events, and...