Special article
Medical errors communication. Ethical and medicolegal issues
La comunicación del error médico. Consecuencias éticas y médico-legales
Carles Martin-Fumadóa,b,
, Màrius Morlansb,c, Francesc Torralbad, Josep Arimany-Mansoa,b
Corresponding author
a Área de Praxis, Servicio de Responsabilidad Profesional, Colegio de Médicos de Barcelona, Consejo de Colegios de Médicos de Catalunya, Barcelona, Spain
b Cátedra de Responsabilidad Profesional Médica y Medicina Legal, Universitat Autònoma de Barcelona, Barcelona, Spain
c Comitè Ètic d’Investigació Clínica (CEIC), Colegio de Médicos de Barcelona, Comitè de Bioètica de Catalunya, Barcelona, Spain
d Universitat Ramon Llull, Barcelona, Spain
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Consecuencias éticas y médico-legales" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Khon<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">1</span></a> defines a medical error as a action that fails to be completed as planned, or the use of an erroneous plan to achieve an end. Grober, in turn, defines a medical error as an act of omission or commission when planning or executing an action that contributes or may contribute to an unintended result.<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The publication of the report <span class="elsevierStyleItalic">To err is human: Building a safer health system</span><a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">1</span></a> was the first publication to be widely recognised by the scientific community, and it identified the scope of preventable medical harm. Since then, several authors have warned of the enormous clinical impact that medical errors can have.<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">3</span></a> In response to this situation, the World Health Organization (WHO) suggested ensuring maximum attention to patient safety (PS) and proposed the establishment and consolidation of scientifically based systems that could improve PS and the quality of health care. Consequently, with the purpose of coordinating, disseminating and accelerating improvements in PS throughout the world, WHO launched the World Alliance for Patient Safety.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Clinical safety or PS is the set of actions aimed at eliminating, reducing and alleviating the adverse results produced as a consequence of the health care process; the field has been acquiring importance within the foundations of current medical practice, in which there is continuous medical, scientific and technological evolution and in which medical professionals are required to permanently assume and provide a high standard of quality medical praxis.</p><p id="par0020" class="elsevierStylePara elsevierViewall">In this sense, in our setting, the National Health System (SNS for its acronym in Spanish) PS Strategy for the 2015–2020 period establishes that a positive culture in PS in health institutions is an essential requirement for the prevention and minimisation of incidents, and to learn from mistakes and reduce the likelihood that they will occur again. It is worth adding that, in order to improve the culture of safety, continuous actions aimed at measuring and improving that area should be carried out, such as informing and training all SNS professionals on safety issues, encouraging effective care training, training teams working in risk management, promoting leadership in safety, communicating and learning from incidents and keeping professionals informed of all assessment data in their health centres by encouraging their active participation in any proposed improvements. However, reliable data into errors are not available in our settings; they should be recognised as possible adverse events that are inherent to the clinical act and they should be incorporated as another quality health-care indicator.<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">4</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">So, although the efforts of institutions and professionals should principally be focused on the prevention of errors, when they do occur, they should be repaired, and the reparation process begins with their communication. On this basis, we propose reviewing the communication of medical errors from an ethical and medical-legal perspective, in addition to the procedures used to carry out such notifications.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Strategies to prevent errors</span><p id="par0030" class="elsevierStylePara elsevierViewall">Medical errors are an inevitable part of medical practice. Assuming, then, the existence of errors and even their under-reporting,<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">5</span></a> identifying how they occur and how they can be prevented is of interest. According to the Swiss Cheese Model of Safety Incidents by James Reason,<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">6</span></a> adverse events usually occur because of the alignment of unintended weaknesses, or holes, in existing barriers, or defences, created to prevent the error. Fortunately for prevention, the review of the system and its defences makes it possible to identify errors. Continuous analysis fosters safety and accident prevention through a proactive process of identifying potential or real errors, causes and effects. The root cause of the error must be identified; it is often a deficiency or decision that, if corrected or avoided, will eliminate an undesirable consequence.<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">7</span></a> In short, given that erring is inevitable, we must learn from errors already performed and from complaints so as not to commit them again.<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">8</span></a> Generically speaking, strategies to reduce adverse events can be summarised by reducing the complexity of the processes, optimising information processing (through visual management, for example), automating wisely and using useful defences.</p><p id="par0035" class="elsevierStylePara elsevierViewall">With regard to the communication of errors, current PS management models include, among its principles, the adequate communication of medical errors. For this to be successful the entire healthcare team is essential and appropriate training is fundamental.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Ethical and moral aspects</span><p id="par0040" class="elsevierStylePara elsevierViewall">The moral ethical considerations of medical errors are based on five principles: autonomy and right to self-determination; beneficence and nonmaleficence; disclosure and right to knowledge; justice and veracity.<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">9</span></a> The enormous implications that these principles acquire in regard to the management of medical errors necessitate their knowledge – and consequently more medical training is necessary.<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">10</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Preferable to the antiquated paternalistic principle, autonomy and the right to decide emphasise patients’ rights to make decisions, maintain their own perspective and determine their medical path based on their personal values and beliefs. The principle of autonomy is often associated with different concepts such as privacy, willfulness, self-control, choosing one's own moral position and accepting responsibility for one's decisions. It should be noted that the Spanish Constitution recognises the right to health protection and emphasises a respect for the principle of autonomy as a fundamental legal health care principle, through Law 41/2002 which regulates patients’ autonomy, rights and obligations in terms of information and clinical documentation. The doctor fulfils this duty through informed consents, the procedure by which the patient, duly informed and competent, freely decides among the available clinical options.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Conversely, when there is a medical error, the principles of beneficence and nonmaleficence oblige the professionals to take the appropriate measures to alleviate and repair the damage caused by such errors.</p><p id="par0055" class="elsevierStylePara elsevierViewall">In addition, patients must be aware of the existence of the medical error, if it occurs, so that they can continue with their own, normal healthcare decision-making process. If an error is not or poorly communicated, it could affect the patient's ability to make decisions, which harms the doctor–patient relationship and may be a possible cause for complaint.<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">11</span></a> Conversely, the systematic dissemination of medical errors can create an opportunity for patients and their families to become part of the solution and in turn strengthen, by improving trust, the doctor–patient relationship.<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">12</span></a> In addition, professionals have an obligation to support the disclosure of medical errors to patients for ethical and practical reasons.<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">12</span></a> This duty is made clear in article 17 of the Organisation of Medical Colleges Code of Conduct.<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">13</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">In parallel, the principle of justice requires health professionals to guarantee that the distribution or allocation of the always limited medical assistance resources does not lead to unforeseen medical errors and, when they do occur, it is a duty of justice to repair them physically, psychically and morally, for which honest communication and sincere apologies are essential.<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">9</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Finally, the principle of veracity, understood as the transmission of complete, accurate and objective information, together with the professional's ability to ensure the patient's understanding of that information, ethically obliges health professionals to disclose and communicate the truth about medical errors that cause harm to patients.<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">14</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Ethics and language. Transparency in communication</span><p id="par0070" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Errare humanum est</span>. Error is an expression of human vulnerability. There is the possibility of error in the exercise of any professional praxis and any therapeutic art. Although they always act according to evidence-based medicine, the health-care team is not professionally infallible and must thus reduce this possibility to the maximum.<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">15</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">The medical team is expected to comply with the requirements established by the deontology code and respect the appropriate protocols, which are to be exercised in prudence – a virtue highlighted by Hippocrates himself and also by Aristotle – and are continuously being formed through awareness of the latest methodologies and scientifically proven therapies. Despite this, in no case can the possibility of error be reduced to zero.</p><p id="par0080" class="elsevierStylePara elsevierViewall">Because of the foregoing, it is a requirement of medical ethics to explore the management of medical error; and in order to do this, remembering the fundamental principles that govern such management is essential. The first principle, the foundation of trust between the professional and their patient, is that of veracity, which requires the professional to communicate truthful information, and to reveal in a clear, intelligible and appropriate manner all the data available in such a way that the patient can understand it.</p><p id="par0085" class="elsevierStylePara elsevierViewall">Because veracity is a basic ingredient of trust, of the empathic agreement between the professional and the patient, if it fails, the fiduciary bond between both is broken. If there is a medical error, be it in the diagnosis, prognosis or treatment, the professional is required to communicate that error to the patient as soon and as diligently as possible.</p><p id="par0090" class="elsevierStylePara elsevierViewall">There are obstacles of all kinds when it comes to truthfully communicating a medical error. The professional is afraid of losing their authority, having a legal case bought against them for malpractice and the damage that can be caused to their professional reputation.<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">16</span></a> Some authors state that few professionals feel that they work within a setting that does not resent errors.<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">17</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">In spite of this, they are obliged to be truthful and to look for ways to mitigate the consequences of an error, in concordance with the principle of nonmaleficence. The patient, by virtue of the principle of autonomy, has the right to decide freely and responsibly after the communication of the medical error. The exercise of this autonomy depends, directly, on the information given by their doctor.</p><p id="par0100" class="elsevierStylePara elsevierViewall">If this professional is transparent in their communication of the error and is able to recognise it and show repentance, the patient might better understand it and the legal consequences of such error may be mitigated.<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">18</span></a> Trying to hide errors in order to maintain their reputation or prevent legal cases being bought against them is bad praxis, especially in a cultural setting such as ours, in which the value of institutional and professional transparency is emerging as an essential part of the social body.</p><p id="par0105" class="elsevierStylePara elsevierViewall">If the doctor chooses to hide the truth, the members of the professional team that have witnessed the error must persuade them to communicate it and, if they are unable to do so, they must disclose it themselves as soon as it is appropriate, in order to mitigate the consequences of such an error. The omission of this responsibility constitutes a serious deontological violation, since it is a form of complicity, by passivity, with the error that has occurred.<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">19</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Patients and their family's expectations in response to the medical error</span><p id="par0110" class="elsevierStylePara elsevierViewall">Systematic reviews of scientific literature on the communication of medical errors show professionals’ limitations when it comes to the communication procedures they use to notify the error and their consequences, as well as the relationship between both.<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">19</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">Research projects specifically designed to meet the expectations of people affected by medical errors are needed. A survey of patients and family members seen in the emergency service of a tertiary hospital<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">20</span></a> revealed that the majority of patients (76%) wanted to be immediately informed of any error and its consequences. The percentage of patients who thought that the error should be reported to government agencies (92%), professional corporations (97%) or hospital committees (99%) was even higher. Patients also overwhelmingly believed that teachers should teach medical students to be honest and compassionate, as well as how to report errors.</p><p id="par0120" class="elsevierStylePara elsevierViewall">The research carried out, using focus groups made up of patients, doctors and a mixture of both,<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">16</span></a> allowed us to gather data on the emotional impact these errors had on patients. Sadness, anxiety and depression were frequent. They are accompanied by fear of future mistakes and anger over the prolongation of hospitalisation. Frustration rises when the error could have been prevented and patients felt the errors were caused by professionals who were not very attentive. They believed that the way the error was communicated would directly affected patients’ emotions: they would feel better if the error was disclosed in an honest and compassionate manner and accompanied by an apology.</p><p id="par0125" class="elsevierStylePara elsevierViewall">The scientific literature reviewed provided valuable information into what patients and their families expected regarding professionals’ communication of information and attitudes. They think that this can help to alleviate mental malaise, which can aggravate the consequences of error. They want to know exactly what has occurred and why, its consequences on their health, the impact on their functioning and how it will affect them in their daily activities. Obviously, they are interested in knowing if the error will be corrected and how any consequences will be corrected.</p><p id="par0130" class="elsevierStylePara elsevierViewall">Their concern leads them to be concerned about future patients, the measures that will be taken to prevent the same errors from occurring again, what the professionals have taken from the occurrence and how they intend to transmit it to medical students and doctors in training. They want to create environments in which patients and their families feel comfortable participating in the diagnostic process and sharing comments and concerns about diagnostic errors.<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">21</span></a> And, of course, they expect an apology as a fair sign of moral reparation. These reasonable expectations must be met by the institutions and their professionals when addressing the difficulty of communicating medical errors to affected patients.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Communicating an error to the patient or their family</span><p id="par0135" class="elsevierStylePara elsevierViewall">To effectively address the notification of errors to patients and families, we must first consider their expectations and emotional involvement<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">16</span></a> as well as those of the professionals involved. The communication of errors cannot and should not be left up to the free will of the professional who is often confused and often requires advice and support.<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">22</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">It is the responsibility of the institution to ensure that everybody involved – patients, relatives and professionals – receive fair treatment. The communication of errors cannot be improvised: it must be planned in accordance with the clear objective of transparency in order to repair any damage that has occurred and the necessary resources to do so must be available. Advice from authors who have researched and reflected on how to appropriately inform patients can be useful when developing protocols to guide procedures based on specific institutional culture and settings.</p><p id="par0145" class="elsevierStylePara elsevierViewall">Their recommendations include<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">23</span></a>: during the first meeting with patients regarding the matter, which must take place as soon as possible, what is known and unknown about the error, and what is being investigated, should already be known.</p><p id="par0150" class="elsevierStylePara elsevierViewall">The meeting should take place in a private and welcoming environment and the professional or professionals involved, the institute director and the person assigned to investigate the error should all be present. A timely way to start the interview is to find out what the patient and/or their family know about the error. Listening to them is the best way to understand and assist them. The language used should be clear, free of technicalities and should avoid speculation. They should be told what is known and what is not known, about the research being carried out to find out the causes and the measures that will be taken to avoid future errors. The door must be left open for a follow-up meeting after the investigation is complete. A sincere apology should be given, and the professional should be prepared for the emotional reaction of those affected. Ensure reparation of the error to the extent possible and offer counselling and psychological and spiritual support as well as the possibility of requesting a second opinion. Although it may not be appropriate during the first interview, the possibility of offering financial compensation should be considered.<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">23</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">Thus, health centres should not only have prevention and detection of adverse events programmes, but should promote the implementation of good clinical practice for the communication of errors guidelines and address the training needs of the professionals in this area.<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">24</span></a> Although a recent survey carried out in the US and Canada shows a tendency towards greater transparency, especially among female and younger health professionals working in the public health sector and those who have experience with the communication of errors,<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">25</span></a> the belief that the notification of errors will be detrimental to the professional-patient relationship in terms of trust and the fear of legal consequences result in an under-reporting and lack of apologising for a medical error.<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">26</span></a></p><p id="par0160" class="elsevierStylePara elsevierViewall">Finally, it should be noted that the IOM correctly emphasises that formally recording a communication of errors and developing a system that facilitates learning from errors is necessary.<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">21</span></a></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">The legal consequences of medical errors: medical professional liability</span><p id="par0165" class="elsevierStylePara elsevierViewall">It is important to note that from a medico-legal perspective, a medical error is not equivalent to professional responsibility. Medical professional responsibility (MPR) is defined as the obligation of doctors to repair and satisfy the consequences of their acts, omissions and voluntary and involuntary errors, within certain limits, committed during the exercise of their profession<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">27</span></a> and necessitates, always and in all cases, three essential requirements: (a) the existence of a cause that generates responsibility, which in medical practice is a medical fault of any conduct characterised by negligence, recklessness or lack of necessary knowledge in the fulfilment of our obligations; (b) the existence of an injury and (c) the existence of a cause–effect relationship between the two previous requirements.<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">28</span></a></p><p id="par0170" class="elsevierStylePara elsevierViewall">In the scope of the MPR, the concept of malpractice is of interest as it applies in those circumstances where the practice of medicine does not conform to what in legal language is known as <span class="elsevierStyleItalic">lex artis</span> (standard of care). This legal concept is used as a synonym for the ‘correct technique’ or, more precisely, as ‘reasonable medical care’ which – if standard norms are followed – a well-trained doctor in the same or similar circumstances would provide. <span class="elsevierStyleItalic">Ad hoc lex artis</span> is the criterion used to assess the appropriateness of a specific medical act carried out by the doctor. The term negligence is applied when a poor-quality medical act has been carried out – either due to lack of attention or due to lack of skill – or when an action that should have been executed, was not. Conversely, the term imprudence is used when acting without paying attention to the recommended precaution due to carelessness, irreverence or haste.</p><p id="par0175" class="elsevierStylePara elsevierViewall">The acts derived from medical professional practice can give rise to different types of MPR, depending on the context in which they take place. Thus, a judicial responsibility can be determined: criminal, civil or contentious-administrative and an extrajudicial route, in addition to an ethical-deontological and Medical College responsibility. Likewise, three levels of health-care responsibility can be identified. The first level is the responsibility that lies with the doctor themselves. The second level is the responsibility of the health institution in terms of the principle of clinical organisation, hierarchy and coordination. And the third level refers to administrations’ responsibilities, as they are responsible for the correct medical-health-care planning and are also obliged to provide it without risk.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Primary, secondary and tertiary victimisation of medical errors</span><p id="par0180" class="elsevierStylePara elsevierViewall">When we refer to the victims of medical errors, there is consensus in the scientific literature that there are several victims. On the first level, also called first victim, we have the patient who has been directly, negatively effected by the medical error and their family impacted by that action. In parallel, the professional who has committed the error is called the second victim<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">29</span></a> and finally, the third victim is the institution or health centre where the medical error occurred.</p><p id="par0185" class="elsevierStylePara elsevierViewall">Even though the risk of a complaining about praxis by default is a major concern in doctors,<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">30</span></a> the so-called second victim, whether a claim has been filed or not, has been forgotten for years. Litigation is extremely stressful and carries an inevitable physical, emotional and behavioural response. Thus, the data available underscore the relevance the impact legal cases against doctors can have, and strongly suggest establishing preventive measures to approach the so-called judicial clinical syndrome,<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">25</span></a> understood as all alterations that modify a medical professional's health status as a result of being subject to a procedural situation, including any physical, psychological and moral alterations that may occur.</p><p id="par0190" class="elsevierStylePara elsevierViewall">In this sense, the primary prevention objective of the judicial clinical syndrome is to ensure the correct assistance, and secondary objectives are to ensure mandatory quality training programmes taught by specialists on improving risk management and issues of responsibility and ensure professionals’ responsibility. Finally, a correct communication of medical errors can help all those involved and, secondarily, prevent this type of victimisation.</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conclusions</span><p id="par0195" class="elsevierStylePara elsevierViewall">Errors, in the practice of medicine, are inevitable. Because of ethical, deontological and clinical safety reasons, these medical errors should be communicated. This communication must be transparent, truthful and made in the best possible conditions. The communication of the error, made through a comprehensive approach, should not be improvised, but should follow protocol developed with an analysis whose purpose was to find the best way possible to communicate these errors, and which considered the victims and their families’ expectations. Proper medical practice today includes the communication of medical errors. For this reason, if an error is not or poorly communicated, it could affect the patient's ability to make decisions, which will, in turn, harm the doctor–patient relationship and may be a possible cause for complaint. On the other hand, an adequate communication of the medical error results in an improvement of the assistance provided, in addition to a lesser impact on the second victim. However, communication of medical error is not easy and requires specific training. Because of the need to acquire such skills to ensure an appropriate practice of medicine, providing specific training during basic medical training would be of interest.</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conflict of interest</span><p id="par0200" class="elsevierStylePara elsevierViewall">The authors declare no conflict of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Strategies to prevent errors" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Ethical and moral aspects" ] 3 => array:2 [ "identificador" => "sec0020" "titulo" => "Ethics and language. Transparency in communication" ] 4 => array:2 [ "identificador" => "sec0025" "titulo" => "Patients and their family's expectations in response to the medical error" ] 5 => array:2 [ "identificador" => "sec0030" "titulo" => "Communicating an error to the patient or their family" ] 6 => array:2 [ "identificador" => "sec0035" "titulo" => "The legal consequences of medical errors: medical professional liability" ] 7 => array:2 [ "identificador" => "sec0040" "titulo" => "Primary, secondary and tertiary victimisation of medical errors" ] 8 => array:2 [ "identificador" => "sec0045" "titulo" => "Conclusions" ] 9 => array:2 [ "identificador" => "sec0050" "titulo" => "Conflict of interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2018-06-28" "fechaAceptado" => "2018-07-26" "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Martin-Fumadó C, Morlans M, Torralba F, Arimany-Manso J. 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