Bakgrund: Vårdskador är vanligt förekommande i både svensk och utländsk sjukvård. Överlag bidrar vårdskadorna med flera dygns förlängda vårdtider och upptar ett stort antal vårdplatser. Detta upptar resurser och kostar samhället många miljarder kronor varje år. Hälso- och sjukvårdspersonal ansvarar för patientsäkerheten i vården, vilket i Sverige är reglerat i lagar och föreskrifter. Dessa finns till för att skydda patienter mot vårdskador och innebär en skyldighet för hälso- och sjukvården att ständigt jobba för att utveckla kvalitet och säkerhet i vården. Syfte: Syftet med litteraturöversikten var att beskriva patienters upplevelser av att drabbas av vårdskada. Metod: En litteraturöversikt enligt Friberg har genomförts. Sökning efter resultatartiklar till översikten gjordes i CINAHL Complete och PubMed. Elva originalartiklar hittades, vilka utgör underlag för resultatet i översikten. Resultat: Med stöd i Katie Erikssons vårdteori identifierades tre huvudkategorier av upplevelser, vilka var vårdlidande, sjukdomslidande och livslidande. Varje kategori hade tillhörande underkategorier där patienternas upplevelser beskrivs. Diskussion: Huvudfynd i resultatet har diskuterats utifrån bakgrund, annan forskning och Katie Erikssons vårdteori. Kommunikation och information från vårdpersonalen efter en vårdskada upplevs av patienter bristfällig. I de fall då kommunikation och information upplevs tillfredställande minskar också vårdlidandet. Patienters upplevelser visar att vårdpersonal inte följer sitt ansvar och befintliga lagar, vilket tycks utgöra ett problem som hämmar kvalitet och säkerhet i vården. I kontrast till de negativa upplevelserna förekommer också positiva upplevelser vilka relateras till god vård innan och efter vårdskadan. / Background: Adverse events are common in Swedish and foreign healthcare. These events overall contribute to several days of prolonged hospital stay and occupies a large number of hospital beds. It occupies resources and costs the society billions of Swedish crowns (SEK) every year. Healthcare professionals are responsible for the patients’ safety in the healthcare, which in Sweden is regulated by laws and regulations. These are designed to protect patients against adverse events and injuries in the healthcare and entail obligations for healthcare professionals to constantly work to develop the quality and safety for the patients in the healthcare.  Aim: The aim of this literature review was to describe patients´ experiences of being affected by an adverse event. Method: A literature review has been performed according to Friberg’s method. The databases CINAHL Complete and PubMed were used for searching articles for this literature review. Eleven original articles were found, which are used to form the results of this review. Results: With support in Katie Eriksson´s theory of caring, three main categories of patients experiences were found, these categories were suffering related to healthcare, suffering from illness, suffering of life. Each category had related subcategories where patients' experiences are described. Discussion: Main findings has been discussed on the basis of the background, other research and Katie Eriksson’s theory of caring. A lack of communication and information from the healthcare professionals after an adverse event was experienced. In cases when the communication and information perceived satisfactorily the suffer were reduced. Patients’ experiences show that healthcare professionals do not follow their responsibilities and the existing laws, which inhibits the quality and safety of the healthcare. In contrast to the negative experiences there were also positive experiences, which are related to good care before and after the adverse event.

Apesar da considerável queda no índice de necrópsias - dado pelo número de necrópsias sobre o número total de mortes - por diferentes motivos tecnológicos, médicos e sociais, esse ainda é o principal exame para conferência de discrepâncias diagnósticas ante-mortem e post-mortem e elaboração de relatórios sobre morbidade e mortalidade e riscos aos pacientes. Nosso estudo compara e descreve diagnósticos ante-mortem e de necrópsia dos pacientes que faleceram no HC-FMRP/USP nos anos de 2010 e 2014. Foram analisadas 1216 necropsias realizadas no HC-FMRP nos anos de 2010 e 2014, sendo pareados os diagnósticos clínico e de necrópsia e classificados segundo o modelo de Goldman (1983) modificado. O índice médio de necrópsias foi de 49%. O percentual médio de discrepâncias diagnósticas maiores foi de 23,4%, com média de 15% de discrepâncias Grau 1 e de 8,3% Grau 2. A faixa etária com maior predomínio de discrepâncias foi de 80 a 100 anos. O diagnóstico de maior prevalência foi a pneumonia, presente em 40% de todos os casos avaliados, dentre os quais 25% apresentaram discrepâncias maiores. Nossos resultados são comparáveis aos registrados na maioria dos estudos mais recentes, em que a porcentagem de discrepâncias maiores em outros hospitais brasileiros se mantém em torno dos 32- 35%, e abaixo dos resultados de estudos internacionais, nos quais a discrepâncias maiores são em torno de 20%. / Although there is a drop on necropsies rates performed in each hospital, which is the number of necropsies by total of deaths, for a number of medical, technological and social reasons, necropsy remains as the main exam to evaluate the discrepancy of premortem and postmortem diagnoses and to estimate, morbidity and mortality and patient risks. Our study compares and describes the diagnoses of patients who died at the HC-FMRP/USP during the years of 2010 e 2014. We analyzed 1216 necropsies performed at he the HC-FMRP in 2010 and 2014, comparing agreement and disagreement between clinical diagnoses and necropsy reports, by the Goldman (1983) modified classification. The mean necropsy rate was 49%. Major discrepancies were 23.4%, with average of 15% for class 1 and 8.3% for Class 2 discrepancies. We found the most common discrepancies occurred at the ages of 80 to 100 years old. The most prevalent diagnostic was \'pneumonia\', found in 40% of all cases studied, among which 25% showed major discrepancies. Our results are compatible with the main recent studies in the field in Brazilian hospitals, in which the major discrepancies are between 32-35% and under the rates of the studies conducted abroad, in which major discrepancies were around 20%.

A presente dissertação busca aproximar o compliance penal ao cotidiano do profissional da medicina. Será analisada a possibilidade de o instituto, que tem por foco a pessoa jurídica, ser aplicado diretamente a pessoas físicas. As questões penais que envolvem a medicina também serão levantadas, com foco nos principais tipos penais que podem se apresentar no dia a dia do profissional. Será discutido se a adoção de normas de compliance consistiria uma assunção de culpa em caso de violação destas, e como esta implementação pode ser vista à luz da teoria da imputação objetiva. Estudaremos a teoria do erro de James Reason e os conceitos de Cultura Justa, ambos ferramentas que auxiliam na criação de normas preventivas. Forneceremos um delineamento geral dos elementos que devem, idealmente, compor o compliance para os profissionais da medicina. Analisaremos acórdãos do Tribunal de Justiça do Estado de São Paulo, com breve apontamentos acerca do atual panorama dos processos criminais que envolvem questões médicas. A conclusão busca responder se a adoção do compliance se justifica frente a todo o analisado, e se é benéfica para os profissionais. / This work tries to approximate the criminal compliance to the medical professional\'s daily life. It analyses the possibility of applying the institute, which is focused on corporations, directly to individuals. Criminal issues involving the field of medicine will also be raised, focusing on main crimes that can arise on daily activities. We will discuss if the adoption of standards of compliance would be seem as an assumption of guilt in case of violations of those, and how this implementation can be seen in light of the Theory of Objective Imputation. We will study the errors theory of James Reason and the concepts of Just Culture, both tools that assist in the creation of preventive standards. We provide a general outline of the elements that should ideally comprise the compliance program to medical professionals. We will analyze decisions of the Court of Justice of the State of São Paulo, with brief notes about the current situation of litigations involving medical issues. The conclusion seeks to answer whether the adoption of compliance methods can be justified at all, and if it is beneficial for the professionals.

Diagnostic errors cause significant patient harm and occur among 15 percent of all clinical diagnoses, but research has yet to effectively target, prevent, and mitigate diagnostic errors from occurring. So far, literature has examined how diagnostician decision-makers perform and reach a clinical diagnosis individually. However, the impact of team-based activities on diagnosis is unknown. The purpose of this study is to describe provider perception on how providers come together as a team in order to complete a clinical diagnosis. As a qualitative descriptive study with overtones of grounded theory, 18 semi-structured interviews of medical intensive care unit providers were audio-recorded, transcribed, and coded generating themes of diagnostic teamwork structure and functioning. Diagnostic teams are described using themes of inter-professional and intra-professional teamwork among roles with and without diagnostic team identity. Novel approaches to diagnostic error research, practice implications for current providers, and applications provided for improving education and team training. By providing preliminary insights on the role of teamwork in diagnostic decision-making, this study may assist future studies that improve diagnostic teamwork and prevent diagnostic errors.

I den svenska vården drabbas uppskattningsvis var tionde patient av en vårdskada, det vill säga en undvikbar skada direkt orsakad av vården (Socialstyrelsen, 2008; Ödegård, 2007). Vårdskador ska registreras som avvikelser som sedan ska analyseras för att finna orsak och ligga till grund för förbättringsarbete (Socialstyrelsen, 2008). Syftet med studien är att beskriva innehållet i de patientavvikelser som registrerats av personal på sjukhus. Innehållet beskrivs avseende vilka händelser som registrerats och vårdpersonalens beskrivningar av händelseförloppet. Studien innehåller både kvalitativa och kvantitativa delar. Den kvalitativa delen genomfördes med innehållsanalys enligt Graneheim och Lundman (2004). Den kvantitativa delen redovisas med hjälp av deskriptiv statistik. Resultatet av studien visar att de flesta avvikelser berör Organisation/regler/resurser, Vård och behandling samt Halk/fall. Patienter i åldern 70-90 år drabbas i störst utsträckning. Händelseförloppet är ofta detaljerat beskrivet. Personal är däremot mindre benägen att skriva vad de anser vara orsak till det inträffade, samt bidra med förbättringsförslag. Teman som kom ur den kvalitativa analysen var: ”Det blir arbetsamt när andra gör fel”, ”Att vara nära men inte inpå” och ”Att lindra lidande”.

The aim of the present research was to investigate the relationships between patient safety culture within hospitals and individual factors on medical practice among physicians. A total of 240 physicians from ten different hospitals completed the Medical Practice Questionnaire, Hospital Survey on Patient Safety Culture, Maslach Burnout Inventory and Eysenck Personality Questionnaire Revised- Abbreviated Form. In order to assess frequency and types of medical errors, Medical Practice Questionnaire was developed by the author. Factor analysis of this Questionnaire demonstrated the existence of four subscales named as Patient Management/Information Delivery Errors, Execution Errors, Procedure Related errors and One Source Errors. ANOVA results revealed that males conduct more Procedure Related Errors than females. In support of the hypothesis, a number of differences observed on patient safety culture between types of institutions that public hospitals received lower scores on most of the safety dimensions. Regression analysis results revealed that personality dimensions and burnout levels were significantly related to types and frequency of errors. Considering significant predictors, while the extravert participants were found to report more Patient Management/Information Delivery, Execution and Procedure Related errors, Neurotics were found to report lower levels of errors on these three dimensions. Regression analysis of burnout levels showed that depersonalization were also associated with these three error dimensions.The level of depersonalization were found to increase the frequency of Patient Management/Information Delivery, Execution and Procedure Related Errors. The research findings however, did not support the assertion in a manner that safety culture dimensions were not found to have main effects on types of errors. The limitations of the current research and implications for further research were discussed.

<p>I den svenska vården drabbas uppskattningsvis var tionde patient av en vårdskada, det vill säga en undvikbar skada direkt orsakad av vården (Socialstyrelsen, 2008; Ödegård, 2007). Vårdskador ska registreras som avvikelser som sedan ska analyseras för att finna orsak och ligga till grund för förbättringsarbete (Socialstyrelsen, 2008). Syftet med studien är att beskriva innehållet i de patientavvikelser som registrerats av personal på sjukhus. Innehållet beskrivs avseende vilka händelser som registrerats och vårdpersonalens beskrivningar av händelseförloppet. Studien innehåller både kvalitativa och kvantitativa delar. Den kvalitativa delen genomfördes med innehållsanalys enligt Graneheim och Lundman (2004). Den kvantitativa delen redovisas med hjälp av deskriptiv statistik. Resultatet av studien visar att de flesta avvikelser berör Organisation/regler/resurser, Vård och behandling samt Halk/fall. Patienter i åldern 70-90 år drabbas i störst utsträckning. Händelseförloppet är ofta detaljerat beskrivet. Personal är däremot mindre benägen att skriva vad de anser vara orsak till det inträffade, samt bidra med förbättringsförslag. Teman som kom ur den kvalitativa analysen var: ”Det blir arbetsamt när andra gör fel”, ”Att vara nära men inte inpå” och ”Att lindra lidande”.</p>

abstract: Critical care environments are complex in nature. Fluctuating team dynamics and the plethora of technology and equipment create unforeseen demands on clinicians. Such environments become chaotic very quickly due to the chronic exposure to unpredictable clusters of events. In order to cope with this complexity, clinicians tend to develop ad-hoc adaptations to function in an effective manner. It is these adaptations or "deviations" from expected behaviors that provide insight into the processes that shape the overall behavior of the complex system. The research described in this manuscript examines the cognitive basis of clinicians' adaptive mechanisms and presents a methodology for studying the same. Examining interactions in complex systems is difficult due to the disassociation between the nature of the environment and the tools available to analyze underlying processes. In this work, the use of a mixed methodology framework to study trauma critical care, a complex environment, is presented. The hybrid framework supplements existing methods of data collection (qualitative observations) with quantitative methods (use of electronic tags) to capture activities in the complex system. Quantitative models of activities (using Hidden Markov Modeling) and theoretical models of deviations were developed to support this mixed methodology framework. The quantitative activity models developed were tested with a set of fifteen simulated activities that represent workflow in trauma care. A mean recognition rate of 87.5% was obtained in automatically recognizing activities. Theoretical models, on the other hand, were developed using field observations of 30 trauma cases. The analysis of the classification schema (with substantial inter-rater reliability) and 161 deviations identified shows that expertise and role played by the clinician in the trauma team influences the nature of deviations made (p<0.01). The results shows that while expert clinicians deviate to innovate, deviations of novices often result in errors. Experts' flexibility and adaptiveness allow their deviations to generate innovative ideas, in particular when dynamic adjustments are required in complex situations. The findings suggest that while adherence to protocols and standards is important for novice practitioners to reduce medical errors and ensure patient safety, there is strong need for training novices in coping with complex situations as well. / Dissertation/Thesis / Ph.D. Biomedical Informatics 2012

O princípio da dignidade humana e da proteção à saúde são decorrentes do direito fundamental à vida. São direitos definidos como prerrogativas mínimas sem as quais o cidadão não existiria dentro do estado democrático de Direito. O pluralismo e os tempos modernos evidenciam outros problemas para a humanidade e, dentre eles, está a obesidade. Trata-se de problema que decorre de um processo histórico, expondo que a alimentação humana mudou substancialmente com a crescente urbanização, somada ao fenômeno da globalização e a disseminação da cultura de consumo, fatores que foram predominantes para o aumento exponencial desta doença. Atualmente é problema grave de saúde pública mundial, que dependendo do país e de acordo com seu desenvolvimento, pode chegar a ser causa de discriminação social, vulnerabilidade e exclusão social. Nesse aspecto, na mesma medida em que a obesidade é crescente em todo mundo, as diversas formas de sanar tal questão também são presentes. Logo, evidencia-se naturalmente constatação do crescimento das chamadas cirurgias bariátricas e, como consequência óbvia de tal aumento, a possibilidade de erros médicos em tais intervenções também é cada vez mais crescente. A medicina é atividade que pela sua própria natureza envolve riscos e lida com o bem mais essencial e fundamental. Assim, o erro médico não pode ser apenado com benevolência. Quaisquer ofensas a tais direitos são repelidas pelo Poder Judiciário que, por meio do instituto da responsabilidade civil, evidencia as premissas básicas de prudência, perícia e diligência, expondo a necessidade de atitudes regulares dos profissionais ligados à atividade médica e o bom senso na apuração de eventual ilícito, bem com condenações justas e igualitárias, pautadas na análise técnica e específica a respeito da conduta do profissional, após a observância de todos os princípios éticolegais e processuais. Assim, neste trabalho busca-se apresentar a tutela jurisdicional da cirurgia bariátrica no que diz respeito a responsabilização do médico por erro, aplicando-se a teoria da responsabilização civil e apontando-se a natureza e a ocorrência dos erros que potencializam e embasam demandas judiciais, bem como os procedimentos regulares e recomendados com o objeto de prevenir a responsabilização. / The principles of human dignity and health protection are derived from the fundamental right to life. They are rights defined as the minimum prerogatives without which citizens could not exist within a democratic state. Pluralism and the modern times point to other issues for mankind, among them, obesity. This is a problem that derives from a historical process, evidenced by changes in human nutrition due to the ever-growing trend of urbanization, in addition to the phenomenon of globalization and we spread culture of consumption, which have been major factors for the exponential growth of this disease. In the present day it presents itself as a serious global public healthcare issue, and depending on which country and stage of development, may become the cause of vulnerability, social prejudice and exclusion. Meanwhile obesity has been shown to be growing worldwide, various means of addressing and solving this matter have also been made available. It may be verified a growth in the number of the so-called bariatric surgeries, and as a direct outcome, the enhanced possibility of medical failure during these procedures. The practice of medicine inherently involves risks while dealing with one´s most fundamental and essential belonging. Hence, medical failure cannot be taken lightly or benevolently. Any offenses to such rights are rebuked by the Judiciary, that bring forth the basic assumptions of prudence, skill and diligence through the institution of civil responsibility, pointing to the need for regular attitudes of medical-related professionals and proper reasoning when examining possible illicit, as well as fair and equal conviction, based on the specific technical analysis regarding the professional´s conduct, whilst observing all procedural, ethical and legal principles. Therefore, this publication intends to present the jurisdictional tutelage of bariatric surgery concerning the physicians accountability for his or her mistake by applying the theory of civil accountability, identifying the nature and occurrence of the errors that provoke or lay grounds for legal action, as well as the regular procedures advised in order to prevent accountability.

Esta dissertação trata da responsabilidade médica decorrente dos danos causados aos pacientes. A questão central do trabalho refere-se a investigar as reais causas para a ocorrência do erro médico que acarreta na geração do dano indenizável. A razão que determinou o interesse pelo estudo da responsabilidade médica foi a constatação nos últimos anos do aumento significativo de demandas judiciais ajuizadas em face dos profissionais da medicina sob alegação de erro médico causador de um dano. Partimos do pressuposto de que os erros médicos muitas vezes ocorrem não por culpa exclusiva do médico que prestou o atendimento, mas sim por outras causas que fogem do controle do médico, tais como a culpa dos hospitais, das operadoras de saúde, do próprio paciente que não seguiu as recomendações médicas, ou até mesmo do Estado, pela falta de investimentos na saúde. Por fim, o trabalho analisa a responsabilidade das operadoras de saúde, dos hospitais e do Estado nas demandas judiciais indenizatórias propostas pelos pacientes. / This thesis will study the medical responsibility regarding the damage caused to the patients. Investigating the real causes of medical errors which lead to compensable damage will be the main purpose of this study. The reason for the interest in the analysis of the medical responsibility is the significant increase in lawsuits filed in recent years against medical professionals alleging a detriment caused by a medical error. We can assume that the so called medical errors dont exclusively occur on account of the medical practitioner who attended the patient but as well very often because of third parts such as hospitals, health insurance companies, patients themselves who did not follow the medical recommendations or even the state through a lack of investment in health. Finally, the responsibility of the aforementioned in lawsuits filed by patients for damages, will be thoroughly analyzed.