Reconocimiento y prevención del error en los cuidados de salud / Awareness and avoidance of error in health care

Los errores de ocurrencia progresivamente creciente en los cuidados de salud, de acuerdo a datos universales, ofrecen un panorama epidemiológico alarmante en la medida que se percibe mayor complejidad de las patologías a atender, sus diagnósticos y tratamientos requieren permanente actualización de conocimientos y habilidades clínicas y tecnológicas, y las demandas de satisfacción y cobertura de costos sufren igualmente exigencias previamente impensadas. En la literatura abunda información sobre las causas y mecanismos de estos incidentes, permite caracterizarlos, medir sus alcances y consecuencias, sistematizar sus efectos y definir conductas para su prevención y manejo. En el presente estudio nos hemos dedicado a mirar los errores surgidos en el área, por incomprensión de su significado y del propio diagnóstico de errores en el cuidado de la salud, y de las probabilidades y formas de resolver los dilemas en asignar responsabilidad a los diferentes participantes del equipo de salud involucrados en esa particular contingencia. También analizamos algunos de los aspectos judiciales derivados y explicitados al clarificar las implicancias legales de estas acciones y la interpretación del clima ético surgido de la percepción de daño que sigue a la trasgresión del contrato virtual médico-paciente. Finalmente se comenta la necesidad de recuperar los valores del compromiso incluido en el cuidado al paciente y la dignidad de las acciones de salud comprendidas en el marco del profesionalismo promovido por el ACP y otras instancias internacionales comprometidas con las responsabilidades asumidas por los profesionales sanitarios.

Errors in Health Care are shown to occur at increasing rates in proportion to the new knowledge, the technological and communication display used in controlling disease and human health impairment. Medical publications and reports, as those coming from allied professions devoid to health care, give plenty information of causes, mechanisms, tendencies, most privileged effects and consequences, classification, characteristics and impact of these issues on the progress of diseases involved and the way it affects the patient - professional relations. These aspects have been the main interest of numerous authors in the pertinent scientific literature. Instead of that focus, we committed our search to look over the errors raised in the field because missed understandings on the significance and the proper diagnosis of errors in health care, and the probability and ways to solve the dilemmas imposed by assigning responsibilities to each participant or the working team involved in the alluded contingency. We also address some of the judicial aspects derived and defined to clarify the legal implications of these actions and the interpretation of the ethic climate raised by the feeling of harm that follows transgression in the professional - patient virtual contract. Finally we comment on the need to restore the high values of the professional endeavour to the patients’ requirements and the dignity of the health actions included under the frame of professionalism promoted by the ACP and other international medical societies of internal medicine and bestowed to the personal responsibility of the sanitary agent.

El hospital docente del siglo XXI: [revisión] / The teaching hospital of the 21st century: [review]

Since their creation, teaching hospitals been associated to complex health care institutions. They have been able to give education and training to health care professionals while providing patient care. Teaching Hospitals have been the home of medical training in formal and informal curriculum. In the past Century, social and economic changes have resulted in pressure to change the mission of academic medical centers. Educational ranking and quality of care do not always correlate, and the learning process mostly occurs through personal example. Several models have been developed to sustain the academic mission at a time of financial challenge. Still, the need to sustain the basic triad of patient care, teaching and research as the core of the academic mission remains constant.

Desarrollo del Departamento de Educación en Ciencias de la Salud en la Facultad de Medicina de la Universidad de Chile / Development of the Department of Education in Sciences of the Health in the Medicine Faculty of the University of Chile

Practically, since it was born, an essential interest of the Faculty of Medicine of the University of Chile has been the continuous actualization of its learning objectives, and the educationimprovement of methodologies to teach and practice competences, therefore accomplishing advanced forming of professional resources, to cover every requirement in sanitary needs in the country. This has been a distinct seal, in the institutional history of the State University of the nation, that has been kept effectively radiating its action, from the more than two hundred years following its foundation age and early incorporation to the patron institution. The main stream orientation of its studies and advances has been, naturally, evolving; surging at the beginning, from the individual initiative of spontaneous academic leaders; thereafter from commended working groups or straight assessors to the executive authorities. Finally, starting the present century, the Department of Health Sciences Education was installed to guide advanced programs design to build the educational fortress needed by vocational selection of teachers, called from the same institution or coming for seemingly sake, from other universities in the country or foreign. The narrative and description of the evolution and actual standing of the Unit, its proposals, projects and perspectives, are offered concisely but thoroughly founded.

En referencia al plagio intelectual. Documento de la Comisión de Ética de la Facultad de Medicina de la Universidad de Chile / Plagiarism

Plagiarism is defined as the intellectual fraud in which an individual attempts to unduly appropriate, for his/her own benefit, the knowledge, ideas or discoveries of someone else. It is not uncommon in academic settings where research is conducted and a creative work is carried out. Due to the dismal consequences of plagiarism, cautionary measures and sanctions are required to avoid it. This paper is intended to warn and promote a discussion about plagiarism. The Faculty of Medicine of the University of Chile and its ethics committee believe that a fight against these type of actions will contribute to prevent their detrimental effects on the moral and intellectual patrimony of our society.

Reivindicando la medicina como profesión científico-humanista / Recovering medicine as a scientific and humanist profession

There is an urgent need, in our society, to recover the real meaning of medicine as a complex of science and humanistic values committed to person's health care. Following the initiative of the American Board of Internal Medicine, the American College of Physicians and the American Society of Internal Medicine (ACP-ASIM) and the European Federation of Internal Medicine, the Medical Professionalism Project has launched a comprehensive declaration to rephrase the social contract between medicine and the society, emphasising the principles and responsibilities that must orient the thoughts and actions of the good physician. The importance, soundness and opportunity of this chart, stimulates an ample dissemination of these concepts and to incorporate them as moral assets, integrating the quality, as experts on a scientific discipline, with the humanistic values provided in these era of increasing bioethical demands

Hacia el médico que nuestros países necesitan: énfasis en la comunicación y en la formación de los docentes / Looking for the physicians that our countries need: emphasis on communications and training of academics

Changes in physicians education and practice induce, nowadays persistent modifications in program's curricula and contents and in learning methodologies, in almost all medical schools and countries. In many of these, and in Chile, this process shows some peculiarities due to the unusual proliferation of medical schools and their differing proposals about the profile of the professional training based on epidemiological considerations and teaching resources. The institutional initiatives leading to reforms, have defined quality and pertinence of these programs and profiles, as it has been the case of the curricular renewal in the University of Chile School of Medicine. Relevant to this reform have been: 1) the introduction of communication skills, pursuing to increase humanistic contents, to improve patient doctor relationship and to accomplish the actual goals of medicine, and 2) capacitating the faculty in the proper disciplines and competencies, for better application of new knowledge and teaching tools to improve learning of the health professionals. Prospective evaluation of these changes will allow us to assess, with best evidence, its definitive role, that is momentarily availed by student's satisfaction

Un fondo competitivo de desarrollo para el fomento de la calidad de la educación superior en Chile: área de la salud / A competitive fund to improve the quality of university education in the area of health care in Chile

In 1997, the Chilean Government and the International Bank for Development convened on a strategy to improve Chilean university education. It was based on quality improvement, effectiveness, relevancy and innovation on university education programs. A US$ 245 millions fund was afforded, for a five years competitive grants program, among certain traditional Universities and Technical Education Institutes. The authors reviewed the projects that won the contests during the first three years in the health area, to determine their impact, demands supported, difficulties and assets. These projects obtained 13.6 percent of the assigned funds (a total of US$ 16.5 millions). Funds were requested mostly to build spaces, obtain equipment, laboratories and computational support. Funds were also requested to carry out methodological changes and teaching improvements. The importance of teaching health sciences in locations outside the Metropolitan area of Santiago, the modification of undergraduate medical curriculum and the development of post graduate networks are emphasized

Formación profesional y su acreditación en medicina, un paradigma en garantía de la fe pública / Professional training and accreditation in medicine: a paradigm to sustain public confidence

Sustaining quality control of learning programs for health professions has become a central issue in university systems, under the pressure of an unexpected merging of new medical schools in Chile, during the last decade, and the massive arrival of other Latin American physicians. Accreditation of institutions and programs represents valid safeguards used in most countries where professional training processes take place. Due guarantee of its quality is required to assure proper health care to people. The authors provide specific arguments to support systematic evaluation and accreditation processes, as those introduced in our country to fulfill the requirements of a high level medical practice

La relación médico-paciente: en un nuevo paradigma bioético / Psycsician-patient relation: in a new bioethical paradigm

El núcleo fundamental y vincular de las actuaciones clínicas de las que emana la relación médico-paciente es el compromiso mutuo de los involucrados. No obstante, esta relación también depende de otros factores que adquieren mucho mayor peso hoy en día. Dentro de dichos factores nos encontramos con el notable y veloz desarrollo de la tecnología y las ciencias, que se ha traducido en la actual amplitud de los conceptos y el desmedro de las nociones que tradicionalmente eran aceptadas, lo que, a su vez, trae consigo la diversificación de la relación médico-paciente. Por otro lado, se produce una trascendente transformación de esta relación, en orden a evolucionar desde una perspectiva fraternal hacia otra más bien contractual, lo cual representa un profundo cambio en las relaciones clínicas. Asimismo, la relevancia de los derechos humanos y, por ende, de la dignidad de la vida y de la persona humana, han provocado que la libertad y la autonomía sean prioritarias, obligando a los facultativos a renunciar al sistema paternalista y dar paso a una relación con sus pacientes mucho más directa y abierta, lo que la mayoría de las veces no es fácil. Todo esto ha traído consigo una transformación de la visión bioética, originándose problemas de interpretación y de juicios y por ello también de toma de decisiones. Por esto es que surge la necesidad de asumir posiciones, pero nos topamos con la dificultad de la innegable diversificación cultural y moral, creándose el riesgo de producir mayor confusión. Con todo, a pesar del respeto y tolerancia a tal diversidad se requiere de más racionalidad y perfeccionamiento para poder evitar los conflictos. El papel de la bioética es, en este sentido, orientar las relaciones clínicas

Errores en Medicina / Medical errors in practice

Untoward effects can result from the various procedures involved in patients care. Because of its risks and consequences it is very important to determine the causal factors of these events to improve the procedures at stake and be sure to obtain from them the results to be expected. Several recent and somehow disturbing reports about the magnitude and type of these said medical errors, have raised interest to review the subject and phase this problem under the scope of a quality control system, as to prevent its occurrence or mitigate its effects when there is no chance to avoid them properly

Planificando la educación médica para las próximas décadas / Planning medical education for the forthcoming years

Accelerated changes in source and contents of knowledge, methodologies and scenarios used in learning, and in the meaning and goals of the educational process, are typical of these times. To characterize future needs, roles and expectations of the various actors involved, is also very unreliable and unpredictable. Performing reiterative strategic analysis, monitoring procedures, doing continuous assessment of results and making permanent adaptations in the educational process to the environmental conditions, are unavoidable means to get secure and pertinent effects from the implemented actions. From this perspective, the University of Chile Faculty of Medicine is formulating its proposals to innovate in curriculum, and strengthen its academic resources and students development

Acreditación de escuelas de medicina: trabajando para la calidad y la confiabilidad pública / Accreditation of medical schools: working for quality and public confidence

Important advances in the accreditation of higher education institutions and programs have occurred in Chile. A definite step forward had been the accreditation of three of the six Medical Schools, considered in the agreement subscribed between the Chilean Medical Faculties Association and the National Committee for Undergraduate Program Accreditation (CNAP). According to this understanding, educational quality was evaluated using international standards and its improvement was encouraged. The accreditation procedure carried out at the University of Chile Medical School is described. Its observation has revealed the difficulties of accreditation procedures and the early benefits obtained after they have been completed. The careful observation of the evaluation procedure will help to improve the used model and to design an effective accreditation instrument that will ultimately improve undergraduate teaching programs

Investigación clínica en Chile: ¿cómo superar una inquietante evolución? / Clinical research in Chile: how to improve its worrying evolution?

There is still great collective paucity in our society in appreciating the importance of scientific work for the devolopment of the nation. In this context, relevant clinical research has ben greatly discouraged. The Ministry of Education and the National Comission for Technical and Scientific research (CONICYT) have been committed, with no outstanding results however, to encourage these activities, specially sustaining individual projects originated in the tradicional universities. Precarious conditions persist as manifested by meager budgets for investigation. Public health policies and organization are scarcely endorsed in locally generated clinical or public health knowledge. Postgraduate training programs, specially doctorates, needed to increase the academic human resources with a consistent scientific potential, are very limited. Recent governmental initiatives, altogether with specific proposals waiting for implementation, would certainly contribute to optimize and promote the revival of our impoverished scenarios in clinical research

El derecho a una atención médica de buena calidad / The right to a good quality health care

Quality has a central role in medical care. The satisfaction of the rights of people to medical care, presupposes good quality medical acts. The meaning of quality goes further than a good attention based on scientific evidence and with competent skills. It comprises patient-physician relationship where professional behavior is evaluated, based on the fundamental principles of bioethics. These principles sustain the measures to control quality of medical actions, to comply with the rights of patients to have access to a good professional care

Autorización para el ejercicio profesional médico en Chile: experiencia de la comisión de reválida de la Escuela de Medicina de la Universidad de Chile período 1984-1999 / Medical practice licensing in Chile: experience of the re-valuation committee of the medical school of Universidad de Chile, 1984-1999

We report the experience of the re-valuation committee of the University of Chile Medical School, in the period 1984-1999. This experience is relevant to the licensing processes in Latin America. We report the political, legal and regulatory backup and the academic criteria used to esatblish different evaluation methodologies. We also communicate the main results obtained. Factors such as the country and University conferring a title, nationality and length of service of the applicant, influence in the percentage of licensure exammination approval. Some modifications to the licensure process should be incorporated but, the overall results obtained, fully justify the existence of this licensure committee

Derechos del paciente en el marco de calidad de la atención médica / Patient rights in the frame of health care quality

Quality in health care is a patient's right. This concept has become progressively acknowledged and demanding since it gains relevancy in planning and delivery of medical care. Defining quality -and other factors that condition and modify it- as a value in medical practice, allows the recognition of the important role that this characteristic has in that setting and how significant it is for clinical decision making. Any reduction in the quality of medicine, by distorting bioethical principles, changes it from a desirable good into a fallacy