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However, patients do not often receive sufficient information about the incidents, not only that, in many cases, these are hidden.<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Multiple factors inhibit doctors from communicating an error when it occurs: fear of being sued, reputation, guilt, loneliness.<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">3</span></a> The concept of “second victims” was introduced<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">4</span></a> in reference to health professionals involved in errors or those who had received a lawsuit due to injury to a patient. Many of the emotions experienced by professionals are also experienced by the patients and their families. Feelings of powerlessness, mistrust or <span class="elsevierStyleItalic">shock</span> are experienced after finding out that something went wrong during the exercise of care.<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">3,5</span></a> Some authors show an increased interest of patients to consider litigation when no one informed them of the error that occurred.<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">6,7</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Depending on the definition of the error, various approaches can be derived regarding its management: the severity and significance of the result of the error, from the near miss with no damage to death. Even the occurrence of various organizational and healthcare system-specific failures.<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">8–11</span></a> In such cases, should all the errors derived from healthcare be reported? Will the doctor always be responsible for communicating such incidents to the patient?</p><p id="par0020" class="elsevierStylePara elsevierViewall">Errors actually occur within teams and, therefore, communications sometimes have to be developed by the healthcare teams themselves. Sometimes patients need to know other team members involved in order to be able to have their confidence restored, not only in the doctor, but in the entire healthcare team and even the medical center itself.<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">12,13</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">However, each case has to be analyzed and managed and there is not such a thing as a standard answer. The lack of institutional support, training and ignorance itself may jeopardize the doctor–patient relationship in the absence of proper communication after an error.<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">14,15</span></a> Communication can preserve confidence and compassion, but it is also an ethical ideal in itself.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Recent policies that are being promoted concerning patient safety are advocating both for the communication as well as an apology regarding errors.<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">16</span></a> This approach related to communicating the causality of the error to patients and/or their relatives has been implemented in many countries, developing basic principles and structures for creating communication and apology programs when errors are made. Strategies to respond to health care errors must simultaneously consider the attitudes and perceptions of team members and patients regarding the communication and apology, and also the protection of all stakeholders in ensuring rights and duties.<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">17</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">However, the fear of being sued after communicating an error is still one of the main barriers to both physicians and lawyers.<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">18–21</span></a> In this sense, international experiences have opted for providing legal and institutional support to medical professionals, encouraging a calm and effective communication of the error following the strategic line of patient safety.</p><p id="par0040" class="elsevierStylePara elsevierViewall">For example, the so-called laws of apology.<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">22</span></a> They are regulations that have been created by different US states to give legal protection to medical professionals when they explain to their patients that an error or failure has occurred. In the US states 37 laws have been implemented. Massachusetts pioneered the implementation of such regulations, creating its own in 1986. 64.86% of the regulations specify that the civil jurisdiction will be the scope of application in case of legal disputes arising in healthcare. On the contrary, none make any references to the criminal scope, leaving unclear whether this protection covers in case of an alleged crime. As for the legal protection of professionals, in 43.24% of the laws, any professional will be protected under the same. In relation to the event described in the regulations, 29.72% specifies as an event or healthcare failure any result derived from the exercise of healthcare that has not been preventable, while 10.81% refers to it as accident and 8.10% as any injury arising from the exercise of healthcare.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Following the analysis of the laws of apology, regarding the type of communication, all these regulations refer to any gesture, conduct or expression that communicates apology, responsibility, empathy, sympathy, kindness, compassion, as well as any other statements derived from the healthcare activity from the professionals to the patients. In this sense, these types of conduct or statements will not be taken into account as evidence of admission of guilt by the referred professionals in case of lawsuit.</p><p id="par0050" class="elsevierStylePara elsevierViewall">However, not all states have these regulations, created and published according to the criteria of each state.<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">23</span></a> To date, there is no assessment on the impact of the laws of apology in the number of communications and apologies issued, the improvement in doctor–patient relationship, and their involvement in the patient safety policies in these states.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Outside the regulatory framework, other experiences have been developed with focus on encouraging communication and apology for the errors at the level of governmental and institutional agreements. The United Kingdom is an example of this. Its strategy toward an open and honest communication after medical errors has been based on the so-called “<span class="elsevierStyleItalic">Duty of candor</span>”, prepared by Robert Francis in 2013.<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">24</span></a> This report recognizes the need to change certain professional healthcare practices for improving quality and patient safety. 290 recommendations were made in professional medical practice, placing the focus on the duty to report episodes in which the patient was injured. These recommendations, which have been extended throughout the country, have been based on the agreement by all British National Health organizations regarding the duty to inform without this implying an admission of guilt or civil and criminal liability. For the purposes of implementation, the British government established the obligation of all centers to incorporate the so called “<span class="elsevierStyleItalic">Duty of candor</span>” through contractual obligations established between health centers and the health authority.</p><p id="par0060" class="elsevierStylePara elsevierViewall">Despite its recent implementation (since 2013 it has been developed in all health organizations), it has established itself as an essential step in advancing transparency and learning about patient safety. However, no studies have evaluated its applicability or its impact on health care.</p><p id="par0065" class="elsevierStylePara elsevierViewall">Can any of these experiences prove useful in Spain? If we analyze the current legislation in Spain, we find that the obligation to healthcare information is found both in recent regulations as well as in the already well established health legislation.<a class="elsevierStyleCrossRefs" href="#bib0270"><span class="elsevierStyleSup">25,26</span></a> Adverse events are not specifically mentioned in any of them, although providing clinical information is mentioned as part of the healthcare services, observing, in any case the right not to be informed. The content of this clinical information shall include at least the purpose and nature of the procedure, the risks and consequences. Also, the attending physician will be the guarantor of compliance with this patient right. In contrast, there is a special mention to the information concerning problems for the community when these involve a public health risk.</p><p id="par0070" class="elsevierStylePara elsevierViewall">In our country, the communication of an adverse event to the patient can effectively lead the user to file a claim or lawsuit in order to obtain a financial compensation for the injury. However, for the economic compensation to be warranted, it is necessary to demonstrate the causal link between the event and the harmful result, the individuality of the injury and the economic value of the impact on the injured user.<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">27</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Having a legal protection similar to the laws of apology of the USA would mean that if doctors communicate or apologize for an error to the patient, this communication (verbal or written) would not be considered as evidence of admission of guilt by the physician.</p><p id="par0080" class="elsevierStylePara elsevierViewall">However, the so-called laws of apology are designed to strengthen communication between doctor–patient from a healthcare strategy viewpoint rather than as a legal tool. This would explain that not all American states have these regulations. Whether with or without laws, the other elements mentioned before need to be proved after informing an adverse event.</p><p id="par0085" class="elsevierStylePara elsevierViewall">If we look at the British experience, this is primarily focused on strengthening the professional practices through the obligation set forth for professionals to communicate these incidents, without the need for a new legislation. Its foundation, that of not needing legal protection for doctors, is based on the obligation to inform, thus, if it is obligatory, it cannot be used against the professional who acts in harmony with it.</p><p id="par0090" class="elsevierStylePara elsevierViewall">In this regard, we think it is necessary to develop strategic plans which address the issue of adverse event communication as we face various barriers when it comes to being able to speak openly and clearly with the patient. How to address the communication according to the type and severity of the incident, the degree of involvement of the healthcare team as well as the characteristics of the injured patient being informed. The need for institutional support, both from the health authority as well as from healthcare organizations is essential to encourage the healthcare team to communicate the error. On the other hand, we need to train medical professionals on how they should report these incidents and provide them with tools, so that the process is right.<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">28</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">Finally, these health policies<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">29</span></a> can be of interest as they encourage transparency and patient involvement in the healthcare process. However, we must continue to work on identifying existing barriers within our healthcare context and improving communication and/or apology after the error in each case.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Giraldo P, Castells X. Errores asistenciales y las leyes de la disculpa, ¿las necesitamos? Med Clin (Barc). 2015;145:341–343.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:29 [ 0 => array:3 [ "identificador" => "bib0150" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "To err is human: building a safer health system" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "L. Kohn" 1 => "J. Corrigan" 2 => "M. 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Journal Information
Vol. 145. Issue 8.
Pages 341-343 (October 2015)
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Vol. 145. Issue 8.
Pages 341-343 (October 2015)
Editorial article
Medical errors and the apology laws, do we need them?
Errores asistenciales y las leyes de la disculpa, ¿las necesitamos?
Visits
3
a Servicio de Epidemiología y Evaluación, Hospital del Mar, Barcelona, Spain
b Instituto Hospital del Mar de Investigaciones Médicas (IMIM), Barcelona, Spain
c Risk Management Foundation of Harvard Medical Institutions, Cambridge, MA, USA
d Escuela Superior de Enfermería del Mar, Centro adscrito a la Universidad Pompeu Fabra, Barcelona, Spain
e Programa de Doctorado en Metodología de la Investigación Biomédica y Salud Pública, Universidad Autónoma de Barcelona, Barcelona, Spain
f Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Madrid, Spain
g Universidad Autónoma de Barcelona (UAB), Barcelona, Spain
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