[Medical errors or deviations in daily health care practice]

There is since 1991 an increasing preoccupation in the English medical literature on adverse events and it has caused that the Institute of Medicine (IOM) has written in 1998 a report that has driven the American Government to make some national plans to find a solution to the problem and to create a committee which deal with the Quality of Health Care in America with the participation of outstanding figures of the policy, sanitary administration, and medical scientific societies. There are deviations between 3.7 and 45.8 in hospital stay. They have Mortality between 4.9 and 5.6. From those between, a 51% and a 54% can be avoided. Only a 27% can be considered as negligence. Deviations happen only a few times because of an isolated personal human factor, but they are associated with many different ocassional and underlying reasons. The analysis of those reasons is essential to understand and to help preventing repetition of that facts. Adverse events does not in many cases mean a training failure but an error in the way that a physician act at a certain moment. The cognitive psychology tries to explain the way that memory behaves, reasoning, and human performance. Adverse events could be not so often, if all the efforts could be driven in direction of prevention, and not in direction of legal punishment. The industry have a lot of experience in applying norms, which could be adapted to any sanitary system, as it is shown in civil aviation industry. All the sanitary personnel should collaborate and this is fundamental to know the facts and the circumstances. However it requires confidentiality and absence of retaliation. It is a fact that there are deviations and its importance requires a cultural change to transform a traditionally defensive attitude into a collaborating conduct in order to improve the quality of the attendance.