Análisis de incidentes críticos: una herramienta para aprender de los errores / Analysis of critical incidents: a tool to learn from errors

El análisis de incidentes es una herramienta de aprendizaje transformativo aplicable en la formación, tanto de pregrado como de posgrado. Dado que se basa en aprender de los errores (cometidos u observados) para evitar que se repitan mediante la adopción de medidas correctoras, su práctica se puede considerar orientada a la mejora continua de calidad asistencial

Incident analysis is a transformative learning tool applicable to training, both undergraduate and postgraduate. Since it is based on learning from mistakes (committed or observed) to avoid repetition by taking corrective measures, its practice can be considered oriented to the continuous improvement of quality of care

El médico como paciente: una experiencia de aprendizaje transformativo / The physician as patient: an experience in transformative learning

Introducción: Los profesionales sanitarios nos enfrentamos a diario con situaciones dolorosas y una gran carga de trabajo. Para abordarlas de manera adecuada se necesita, además de conocimientos y habilidades científico-técnicas, actitudes empáticas. Es difícil empatizar si no se poseen ciertas habilidades personales relacionadas con la conciencia plena, el autoconocimiento y la gestión emocional. Pero esto no se enseña en las facultades y, con frecuencia, los estilos de respuesta -sobreimplicación o excesivo distanciamiento- resultan perjudiciales a largo plazo. Desarrollo: Se realiza una reflexión estructurada sobre un incidente acontecido en la práctica profesional, atendiendo tanto a los aspectos clínicos como a los relacionados con la inteligencia emocional del médico. La reflexión estructurada ha permitido, además de actualizar conocimientos sobre rabdomiólisis, identificar aspectos mejorables relacionados con actitudes personales del profesional. Por una parte, ha ofrecido una oportunidad para el autoconocimiento, el cuestionamiento de las propias creencias y la revisión de los valores subyacentes a éstas. Por otra, ha revelado la importancia de trabajar con conciencia plena, para no desgastarse y para entender mejor a los pacientes. Conclusión: reflexionar sobre la propia experiencia permite aprender de ella, siendo un instrumento potente para mejorar el cuidado de los pacientes y las habilidades comunicativas de los profesionales

Introduction: Health professionals deal with painful situations and heavy work-load every day. In addition to scientific and technical knowledge and skills, an attitude of empathy is required in order to address these realities adequately. Showing empathy is difficult without possessing certain abilities associated with self-awareness, self-knowledge and the management of emotions. These skills, however, are not taught in centres of academic learning, and our way of solving this issue –overinvolvement or excessive distance- is in the long run deleterious. Development: An incident occurring in the course of professional practice is used as the basis for structured reflection, from both its clinical aspects and its implications’ perspective, in terms of the physician’s emotional intelligence. In addition to updating our knowledge of rhabdomyolysis, this process of structured reflection made it possible to identify areas of potential improvement in the personal attitudes of health-care professionals. On the one hand, it was an opportunity for deepening self-knowledge, questioning our own beliefs, and reviewing the values which underlie them. On the other hand, it revealed the importance of working mindfully to avoid burn-out and to better understand our patients. Conclusion: Reflection upon our own experience allows us to learn from it, and supplies us with a powerful tool to improve our patients’ care and our professional communication skills

Age differences in presentation, diagnosis pathway and management of colorectal cancer.

BACKGROUND: The gap in survival between older and younger European cancer patients is getting wider. It is possible that cancer in the elderly is being managed or treated differently than in their younger counterparts. This study aims to explore age disparities with respect to the clinical characteristics of the tumour, diagnostic pathway and treatment of colorectal cancer patients. METHODS: We conducted a multicenter cross sectional study in 5 Spanish regions. Consecutive incident cases of CRC were identified from pathology services. MEASUREMENTS: From patient interviews, hospital and primary care clinical records, we collected data on symptoms, stage, doctors investigations, time duration to diagnosis/treatment, quality of care and treatment. RESULTS: 777 symptomatic cases, 154 were older than 80 years. Stage was similar by age group. General symptoms were more frequent in the eldest and abdominal symptoms in the youngest. No differences were found regarding perception of symptom seriousness and symptom disclosure between age groups as no longer duration to diagnosis or treatment was observed in the oldest groups. In primary care, only ultrasound is more frequently ordered in those <65 years. Those >80 years had a significantly higher proportion of iron testing and abdominal XR requested in hospital. We observed a high resection rate independently of age but less adjuvant chemotherapy in Stage III colon cancer, and of radiotherapy in stage II and III rectal cancer as age increases. CONCLUSION: There are no relevant age disparities in the CRC diagnosis process with similar stage, duration to diagnosis, investigations and surgery. However, further improvements have to be made with respect to adjuvant therapy.

[Shared governance and reasonableness as ethical contributions to health policy]. / La gobernanza compartida y la razonabilidad como aportaciones éticas a la política sanitaria.

Health is one of the fundamental human rights. Recognizing it as a right means that the State has an obligation to ensure a minimum level of opportunities is maintained, and to restore it when lost. This minimum level may not be covered in periods of economic crisis, such as the one we are currently experiencing.Managed care, focused on economic questions, emerged after the crisis of 1973 in order to help make clinical decisions based on economic factors. In practice, the result of managed care was to turn economic cost control into an end in itself while forgetting about equity; something for which it has been challenged from an ethical perspective. Since then, many authors have attempted to reconcile efficiency and equity in health management, but the debate remains open.In this article, and basing our approach on the theories of P. Ruger and Norman Daniels, we argue that shared health governance and accountability for reasonableness can offer significant ethical contributions in the process of achieving an efficient and fair health system. In the model we propose, citizens, professionals and health institutions all play an active role in capacity building in the field of health. These capacities are related to healthy lifestyles, accessible and transparent information, the promotion of self-care, the acquisition of knowledge, skills and appropriate attitudes, leadership based on values and co-responsibility to achieve set goals in a reasonable way. If we develop these capacities, we will have used the current economic crisis as an opportunity for improving ethical practice in the field of health.

La gobernanza compartida y la razonabilidad como aportaciones éticas a la política sanitaria / Shared governance and reasonableness as ethical contributions to health policy

La salud es uno de los derechos humanos fundamentales. Reconocerla como tal conlleva la obligación estatal de garantizar un mínimo de oportunidades para mantenerla o recuperarla cuando se pierde. Ese mínimo puede quedar sin cubrir en épocas de crisis económica, como la que estamos viviendo. La medicina gestionada (managed care) centrada en lo económico surgió tras la crisis de 1973, con el objetivo de condicionar las decisiones clínicas por factores económicos. En la práctica, la medicina gestionada convirtió el control de los costes económicos en un fin en sí mismo olvidando la equidad, por lo que ha sido cuestionada éticamente. Desde entonces, muchos autores han afrontado la tarea de compatibilizar eficiencia y equidad en la gestión sanitaria, pero el debate sigue abierto. Partiendo de los pensamientos de Jennifer P. Ruger y Norman Daniels, defendemos que la gobernanza sanitaria compartida y la rendición de cuentas atendiendo a criterios de razonabilidad pueden ser dos importantes aportaciones éticas para lograr un sistema sanitario eficiente y justo. En el modelo que proponemos, tanto los ciudadanos como los profesionales y las instituciones sanitarias juegan su papel en cuanto al desarrollo de capacidades en el ámbito de la salud. Tales capacidades se refieren a estilos de vida saludables, información accesible y transparente, promoción de autocuidados, adquisición de conocimientos, habilidades y actitudes adecuadas, liderazgo basado en valores y co-responsabilidad para alcanzar los objetivos establecidos de modo razonable. Si desarrollamos estas capacidades habremos aprovechado la actual crisis económica como oportunidad de mejora ética en el ámbito sanitario (AU)

Health is one of the fundamental human rights. Recognizing it as a right means that the State has an obligation to ensure a minimum level of opportunities is maintained, and to restore it when lost. This minimum level may not be covered in periods of economic crisis, such as the one we are currently experiencing.Managed care, focused on economic questions, emerged after the crisis of 1973 in order to help make clinical decisions based on economic factors. In practice, the result of managed care was to turn economic cost control into an end in itself while forgetting about equity; something for which it has been challenged from an ethical perspective. Since then, many authors have attempted to reconcile efficiency and equity in health management, but the debate remains open.In this article, and basing our approach on the theories of P. Ruger and Norman Daniels, we argue that shared health governance and accountability for reasonableness can offer significant ethical contributions in the process of achieving an efficient and fair health system. In the model we propose, citizens, professionals and health institutions all play an active role in capacity building in the field of health. These capacities are related to healthy lifestyles, accessible and transparent information, the promotion of self-care, the acquisition of knowledge, skills and appropriate attitudes, leadership based on values and co-responsibility to achieve set goals in a reasonable way. If we develop these capacities, we will have used the current economic crisis as an opportunity for improving ethical practice in the field of health (AU)

Factors related with symptom duration until diagnosis and treatment of symptomatic colorectal cancer.

BACKGROUND: Colorectal cancer (CRC) survival depends mostly on stage at the time of diagnosis. However, symptom duration at diagnosis or treatment have also been considered as predictors of stage and survival. This study was designed to: 1) establish the distinct time-symptom duration intervals; 2) identify factors associated with symptom duration until diagnosis and treatment. METHODS: This is a cross-sectional study of all incident cases of symptomatic CRC during 2006-2009 (795 incident cases) in 5 Spanish regions. Data were obtained from patients' interviews and reviews of primary care and hospital clinical records. MEASUREMENTS: CRC symptoms, symptom perception, trust in the general practitioner (GP), primary care and hospital examinations/visits before diagnosis, type of referral and tumor characteristics at diagnosis. Symptom Diagnosis Interval (SDI) was calculated as time from first CRC symptoms to date of diagnosis. Symptom Treatment Interval (STI) was defined as time from first CRC symptoms until start of treatment. Nonparametric tests were used to compare SDI and STI according to different variables. RESULTS: Symptom to diagnosis interval for CRC was 128 days and symptom treatment interval was 155. No statistically significant differences were observed between colon and rectum cancers. Women experienced longer intervals than men. Symptom presentation such as vomiting or abdominal pain and the presence of obstruction led to shorter diagnostic or treatment intervals. Time elapsed was also shorter in those patients that perceived their first symptom/s as serious, disclosed it to their acquaintances, contacted emergencies services or had trust in their GPs. Primary care and hospital doctor examinations and investigations appeared to be related to time elapsed to diagnosis or treatment. CONCLUSIONS: Results show that gender, symptom perception and help-seeking behaviour are the main patient factors related to interval duration. Health service performance also has a very important role in symptom to diagnosis and treatment interval. If time to diagnosis is to be reduced, interventions and guidelines must be developed to ensure appropriate examination and diagnosis during both primary and hospital care.

Sin reconocimiento recíproco no hay calidad asistencial / Without reciprocal recognition there is not quality of care

Aspectos básicos de la relación clásica médico-enfermo han entrado en crisis en la medicina actual. Dificultades de comunicación, infravaloración de la empatía, o interposición de criterios economicistas están dando lugar a estilos asistenciales que facilitan la cosificación de los pacientes, el menosprecio de los sanitarios y la indiferencia –de unos y otroshacia las medidas colectivas de la salud. Principios básicos de esa relación tales como calidad, justicia, autonomía del paciente y beneficencia podrían aparecer débiles de contenido. En este trabajo se propone aplicar el concepto de “reconocimiento recíproco” procedente de la filosofía, para “recargar” de contenido diferentes aspectos de la relación clínica. En un aspecto “interno”, abordando la identidad de los protagonistas: el reconocimiento recíproco buscaría potenciar tanto la del paciente como la del profesional. En un aspecto “externo”, buscaría incidir en la calidad de la asistencia, objetivo fundamental de la relación clínica. Con el reconocimiento recíproco aplicado a la salud pública se refuerza el principio de justicia facilitando la construcción de una identidad como ciudadanos de derechos(AU)

Understanding the classic doctor-patient relationship has entered a crisis in medicine today. Communication difficulties, underestimation of empathy, or bringing economic criteria are leading to care styles that facilitate the objectification of patients, contempt for doctors, and indifference of both to collective measures of health. Basic principles of this relationship such as quality, justice, patient autonomy and beneficence may appear weak content. We intend to apply the concept of "reciprocal recognition" from philosophy to "recharge" content different aspects of the clinical relationship: a look "inside", dealing with the identity of the protagonists seek to promote it by using reciprocal recognition of both patient and the professional. In one aspect "external", focusing on the quality of care, a key objective of the clinical relationship.With reciprocal recognition, issues of justice and equity are reinforced through public health, building an identity of citizens with rights(AU)

[Without reciprocal recognition there is not quality of care]. / Sin reconocimiento recíproco no hay calidad asistencial.

Understanding the classic doctor-patient relationship has entered a crisis in medicine today. Communication difficulties, underestimation of empathy, or bringing economic criteria are leading to care styles that facilitate the objectification of patients, contempt for doctors, and indifference of both to collective measures of health. Basic principles of this relationship such as quality, justice, patient autonomy and beneficence may appear weak content. We intend to apply the concept of "reciprocal recognition" from philosophy to "recharge" content different aspects of the clinical relationship: a look "inside", dealing with the identity of the protagonists seek to promote it by using reciprocal recognition of both patient and the professional. In one aspect "external", focusing on the quality of care, a key objective of the clinical relationship. With reciprocal recognition, issues of justice and equity are reinforced through public health, building an identity of citizens with rights.

Diagnosis delay and follow-up strategies in colorectal cancer. Prognosis implications: a study protocol.

BACKGROUND: Controversy exists with regard to the impact that the different components of diagnosis delay may have on the degree of invasion and prognosis in patients with colorectal cancer. The follow-up strategies after treatment also vary considerably. The aims of this study are: a) to determine if the symptoms-to-diagnosis interval and the treatment delay modify the survival of patients with colorectal cancer, and b) to determine if different follow-up strategies are associated with a higher survival rate. METHODS/DESIGN: Multi-centre study with prospective follow-up in five regions in Spain (Galicia, Balearic Islands, Catalonia, Aragón and Valencia) during the period 2010-2012. Incident cases are included with anatomopathological confirmation of colorectal cancer (International Classification of Diseases 9th revision codes 153-154) that formed a part of a previous study (n = 953).At the time of diagnosis, each patient was given a structured interview. Their clinical records will be reviewed during the follow-up period in order to obtain information on the explorations and tests carried out after treatment, and the progress of these patients.Symptoms-to-diagnosis interval is defined as the time calculated from the diagnosis of cancer and the first symptoms attributed to cancer. Treatment delay is defined as the time elapsed between diagnosis and treatment. In non-metastatic patients treated with curative intention, information will be obtained during the follow-up period on consultations performed in the digestive, surgery and oncology departments, as well as the endoscopies, tumour markers and imaging procedures carried out.Local recurrence, development of metastases in the follow-up, appearance of a new tumour and mortality will be included as outcome variables.Actuarial survival analysis with Kaplan-Meier curves, Cox regression and competitive risk survival analysis will be performed. DISCUSSION: This study will make it possible to verify if the different components of delay have an impact on survival rate in colon cancer and rectal cancer. In consequence, this multi-centre study will be able to detect the variability present in the follow-up of patients with colorectal cancer, and if this variability modifies the prognosis. Ideally, this study could determine which follow-up strategies are associated with a better prognosis in colorectal cancer.

El paciente. ¿Es posible ayudar a los pacientes a decidir? / Patient series. Is it possible to help patients to decide?

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