Alberca R
Ex Jefe del Servicio de Neurología, Hospital Universitario Virgen del Rocío, Sevilla, España.
Neurologia. 2010 Oct;25 Suppl 1:52-60. doi: 10.1016/S0213-4853(10)70051-7.
In 1999, the American Institute of Medicine reported an enormous rate of medical errors, representing the fifth cause of death. In Spain, there is no reliable information on the number and nature of medical adverse events, but the situation is probably similar to that described in the USA in 1999, if not higher. Diagnostic errors account for more than half of neurological adverse events and these errors can be catastrophic if the natural progression of the neurological disorder causes severe sequels or even death when the patient is left untreated. To improve patient safety, research must be undertaken to determine how these errors are produced and to develop strategies to prevent inappropriate conduct. Among many other elements, it is important to create teamwork, improve neurological knowledge among general practitioners and residents, to design clinical practice guidelines aimed at patient safety, and to promote policies that reward the absence of errors. In general, medical errors are neither exclusively due to lack of experience nor to insufficient medical knowledge, but rather to faulty organization of medical care. Therefore, it is preferable to monitor healthcare organization rather than to blame the individual supposedly responsible for the error.
1999年,美国医学研究所报告称医疗差错发生率极高,是第五大致死原因。在西班牙,关于医疗不良事件的数量和性质没有可靠信息,但情况可能与1999年美国描述的情况相似,甚至可能更严重。诊断错误占神经科不良事件的一半以上,如果神经疾病的自然进展导致严重后遗症,或者患者未得到治疗而死亡,这些错误可能是灾难性的。为提高患者安全,必须开展研究以确定这些错误是如何产生的,并制定预防不当行为的策略。在许多其他因素中,建立团队合作、提高全科医生和住院医生的神经学知识、设计以患者安全为目标的临床实践指南以及推行奖励无差错的政策非常重要。一般来说,医疗差错既不完全是由于缺乏经验,也不是由于医学知识不足,而是由于医疗护理组织不当。因此,最好是监测医疗保健组织,而不是指责被认为应对错误负责的个人。