Litigability and defensibility in neurology and neurosurgery. A “therapeutic” model for handling claims for malpractice care

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"idiomaDefecto" => true "cabecera" => "Special article" "titulo" => "Litigability and defensibility in neurology and neurosurgery. A “therapeutic” model for handling claims for malpractice care" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "22" "paginaFinal" => "30" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "José Aso Escario" "autores" => array:1 [ 0 => array:4 [ "nombre" => "José" "apellidos" => "Aso Escario" "email" => array:1 [ 0 => "jaso@maz.es" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "1" "identificador" => "fn0005" ] ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Neurocirugía, Hospital MAZ, Zaragoza, Spain" "identificador" => "aff0005" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Litigabilidad y defendibilidad en neurología y neurocirugía. Un modelo “terapéutico” para el manejo de reclamaciones por mala praxis asistencial" ] ] "textoCompleto" => "IntroductionThe latest official national data come from the INSALUD (Instituto Nacional de la Salud [National Institute of Health]) Inspectorate. Between 1 January 1995 and 31 December, 2000, 2136 claims were registered. In total, 43 resulted in conviction and 298 were settled before going to trial<a class="elsevierStyleCrossRefs" href="#bib0005">1,2</a>.By specialty, emergency medicine had the highest number of claims (23.8%), followed by obstetrics and gynaecology (18.2%), traumatology (11.2%), surgery and general medicine (7%), ophthalmology (4.6%), neurosurgery (4.6%), cardiology (3.7%), paediatrics (3.7%), psychiatry (2.3%) and urology (2.3%).In the database of the Barcelona College of Physicians, traumatology was top in claims, followed by gynaecology and obstetrics. Neurosurgery ranks eighth most common<a class="elsevierStyleCrossRef" href="#bib0015">3</a>.Probably the only updated national data on the matter come from the Patient Ombudsman Association in its 2017–2020 reports<a class="elsevierStyleCrossRefs" href="#bib0020">4–7</a>. The incidence by specialty is summarised in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>. Neurosurgery occupied ninth place in 2017, but has disappeared from the top ten since 2018. The reasons for claims are listed in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a><a class="elsevierStyleCrossRef" href="#bib0040">8</a>.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia>Recently, the United States has seen a reduction in the number of awarded claims, with an increase in the average cost of compensation and in the frequency of compensation for catastrophic harm<a class="elsevierStyleCrossRef" href="#bib0045">9</a>. Among the reasons for this decline could be improvements in safety systems, including checklists and protocols for changes in healthcare workload. Furthermore, the way in which institutions and insurers resolve claims could be an explanation if the institution considers it to be a problem with the system rather than the fault of a specific professional<a class="elsevierStyleCrossRef" href="#bib0050">10</a>.These and other policies can mitigate the so-called “pena de banquillo [bench penalty]” (or clinical-judicial syndrome)<a class="elsevierStyleCrossRef" href="#bib0055">11</a>, which makes the professional prone to errors and transforms their performance into defensive medicine.In this context, we think that a unified approach is needed for an issue which, as we see it, is increasingly widespread. However, before we can present our model, it is necessary to review two concepts rarely mentioned in the literature<a class="elsevierStyleCrossRef" href="#bib0060">12</a>.Litigability and defensibilityLitigability is the likelihood that a claim for malpractice will be filed, in any area (administrative or judicial).Defensibility is the ability to defend the fact that the healthcare action is correct.For example, neurosurgery would have a high litigability, but its defensibility rate would also be very high (90%). In contrast, radiology would present poor litigability, but its defensibility would be very low, due to the high chance of documenting errors.Litigability does not depend so much on technical aspects of healthcare as on ethical factors. Elements such as a good user-healthcare professional relationship, adequate social customs, an “enabling” environment, quality of information, attitude of the healthcare team, or the perception that the patient has of the quality of care, are key factors in litigability<a class="elsevierStyleCrossRefs" href="#bib0065">13,14</a>. Along these lines, for example, is the fact that it is much higher for male doctors than their female counterparts<a class="elsevierStyleCrossRef" href="#bib0075">15</a>. Females would be better able to interact emotionally with the patient<a class="elsevierStyleCrossRef" href="#bib0080">16</a>.In contrast, defensibility does depend on the technical aspects of healthcare. As such, the degree of adjustment to the standard of care (Lex Artis [standard of care] ad hoc) reinforces or weakens defensibility.To understand the reasons behind claims, prevent them and manage potential healthcare failures, it is essential to develop protocols aimed not only at increasing defensibility but also at reducing litigability. We will try to offer a model that serves both purposes. This is what we call the “medical malpractice therapeutic model”, based on applying preventive, diagnostic and therapeutic tools as if it were a disease.How to reduce litigabilityWe will highlight ethical elements and other non-technical healthcare factors.Creating an enabling environmentSeveral factors influence the patient's perception of care, even before the doctor's intervention: comfort, the length of the wait, the treatment given by the auxiliary staff, the image of the environment (rooms, furniture, cleanliness, etc.), the appearance of the doctor and the auxiliary personnel, etc. Nobody goes to hospital for reasons other than illness, and nobody expects the environment to contribute to increasing its effects, but, rather, to mitigate them.Dedication to information effortsThis includes it being extended to family members to the extent that the patient allows it, managing bad news or sensitive information well (information in stages, collaboration with other professionals in expert advice, etc.), guaranteeing full, accessible, continuous information, and dedicating the necessary time to it. Maintaining internal consistency of the information and ensuring that the entire team is up to date with the information is another key factor.It has been calculated that 30%–40% of healthcare time is invested in information tasks and that claims increase inversely to the time spent on each consultation<a class="elsevierStyleCrossRef" href="#bib0085">17</a>.Administrations must keep in mind that the time required for healthcare is incompatible with many of the ratios that are considered normal or suitable in Spain.Yet the best information is not a guarantee of adequate understanding by the patient. In neurosurgery, only about 43% of the information is understood immediately after it is provided. After six weeks, this percentage drops to 38.4%<a class="elsevierStyleCrossRef" href="#bib0090">18</a>. In other specialties, 43.6% of the patients do not retain anything and 19.6% only retain 25% of the information<a class="elsevierStyleCrossRef" href="#bib0095">19</a>.These data indicate that, in delayed complaints, the versions of events offered by patients may not appropriately reflect the actual information provided at the time, which is relevant to defensibility.In practice, claims about problems related to informed consent are rare (32%). However, sometimes the doctor is not very accommodating to the patient or their relatives when providing information. This fosters complaints. Regarding deaths, claims have been filed simply to obtain the medical history, due to a lack of information about what happened and the doctors refusing to provide it. Generally, the explanations given in this situation and the death discharge report (which is also a medical discharge) can clarify many situations that, otherwise, would end up in court, exceeding the administrative scope to which they could have been reduced.Personalisation of careThis should also be extended to the rest of the team members (it is advisable to have a person in charge for each professional stratum).Promoting a good user-healthcare professional relationship (formerly called patient-doctor, or other healthcare professionals)The reification of healthcare is contrary to medical ethics. The health worker is obliged to develop empathy, be polite and courteous towards patients and their relatives. Several studies have suggested that the deterioration of this relationship fosters claims<a class="elsevierStyleCrossRef" href="#bib0100">20</a>. The perception of a caring attitude or empathy for the patient reduces litigability. There are a number of skills, such as being able to understand and endorse the patient's perspective, as well as reflecting on the patient's responses<a class="elsevierStyleCrossRef" href="#bib0105">21</a>, that work favourably in this regard. Disparaging comments about the patient, family members or other professionals have the opposite effect.Influencing the systemIn 3%–5% of claims, the outcome would have been the same in “the best hands and with the best care”. However, 95% of cases are caused by a failure. This deficiency is most often (85%) due to the system and not the healthcare professional<a class="elsevierStyleCrossRef" href="#bib0085">17</a>.A common cause of complaints is waiting lists. These are caused by the system, although the professional must warn the patient about the system and the risks of delay.The system has no criminal liability. On this basis, the undeniable responsibility that this has in cases of the poor operation of institutions is rarely realised either by the injured party or by the doctor involved.It is also much easier to place responsibility on a natural person rather than a legal entity, since the latter is somewhat immeasurable. This means that this burden of responsibility does not tend to be directed against the system. A further pernicious consequence is that the healthcare deficiency may go uncorrected.Normally, we healthcare workers are in the best position to notice the deficiencies of the system and communicate its failures. Unfortunately, this is rare in practice. On the one hand, this is due to the tendency to make normal what might not be normal due to a misunderstood “force of habit.” Another cause is the fear that the system will react with hostility against those who want to change it.It must be remembered that, like any public worker, healthcare professionals are obliged to report any defects they observe to their regulatory superior. If this were done in practice, it is likely that many claims would take a turn towards the imputation of the system or its administrative managers.Recalling the legal aphorism “If it is not written down, it does not exist,” it is important to promote the culture of communication of deficiencies in writing. Administrative managers, for their part, should not see these communications as a hostile action but rather as an obligation of the healthcare professional, and channel it towards a risk management scenario rather than a protest.The involvement of the institutions is therefore crucial. The development of communication and resolution strategies in the form of information programmes, transparency, apologising and compromising can reduce litigation<a class="elsevierStyleCrossRef" href="#bib0045">9</a> even after the adverse event has occurred<a class="elsevierStyleCrossRef" href="#bib0110">22</a>, although some do not agree that the so-called apology laws<a class="elsevierStyleCrossRef" href="#bib0115">23</a>, in isolation, can lead to a lower incidence of claims<a class="elsevierStyleCrossRef" href="#bib0120">24</a>.Identifying and managing situations involving risk wellThere are various scenarios that carry a greater medical-legal risk. To decrease litigability (and also to increase defensibility), an important task is to identify and manage them well. These include the following:First contactProper documentation of this is advised. The role of emergency nursing history has been emphasised, as it is often the best testimony to the patient's entry point into the system. The collection of medical history is important, since it is not uncommon for its lack of documentation to have dire consequences. If the patient is referred from another centre, any previous diagnosis should be collected.Change of healthcare workloadThis change is usually imposed by the system. For example, patients who are entitled to care in another centre, or transfers outside or within the hospital itself.Technically, this involves a failure in the healthcare relationship, which is why communication between the sender and the receiver is essential. It is recommended to provide a detailed report of the patient's status at discharge, preceded, if necessary, by telephone communication.The receiving department or professional should not assume that the patient's situation has not changed since the transfer, so it is recommended to repeat the essential tests and, of course, the clinical examination. In short, it is recommended that the clinical history be taken again. The recipient must see the case as new, and the sender must guarantee a quality of care at the destination equal to or better than the prior care, never worse.Medical dischargeIt is mandatory that discharges, whatever their type (hospital, death, voluntary, transfer, etc.), are closed with an epicrisis.In addition to technical issues, it is advisable to ensure the involvement of the family or take an interest in post-discharge circumstances (care, housing, etc.) in sensitive cases, or those with potential medical-legal risk.In situations carrying risk, it is recommended that the discharge document be signed collectively (sometimes with the inclusion of the centre director) and that including reports from other professionals involved in the process be considered.There are some simple rules that can help manage the discharge process effectively. One last look at the medical history before the patient leaves the department is highly recommended. A last visit to the patient, documenting his/her condition at the time of discharge, is also advisable.It is also recommended that the type of therapeutic instructions be recorded, and it be specified as to whether they are “Mandated” or “If required”.Repeated requests for careThis usually involves a patient who has already been seen and who comes back for the same problem. In the emergency department, the “third time” rule is usually applied, whereby a patient who comes to the emergency department for the third time within a short period of time (a few days) must be admitted for assessment. This rule cannot be taken at face value, but it does emphasise the risk of this situation and the need to study the case in detail.Rejection of medical adviceConsent is a contract between the patient and healthcare provider that can be broken by the former (rejection of medical advice) or by the latter (in exceptional situations such as mistrust or refusal to follow instructions).The Spanish Health Law (Article 10, Section 9) establishes the right to “refuse treatment, except in the cases specified in Section 6”.It is essential that any refusal is documented in writing (Law 41/2002). The law allows this record to be made by the physician through annotation in the clinical history in the event that the patient refuses to sign the refusal form that is usually provided by all centres.Resident performanceResidents are not immune from claims or convictions. However, since they must be supervised<a class="elsevierStyleCrossRef" href="#bib0125">25</a>, the tutor is answerable, as long as there is no overreach.Judgements in this regard assume that the resident acquires a progressive responsibility, and that this depends on the evaluations carried out. Thus, the resident does not have a “position of guarantor and a duty to act on his/her own and independently, for which he/she could be liable, when in the case of the provision of a certain professional diligence, it is necessary to have all the technical professional training, having finished and completed it, in order to be able to assess whether he/she has failed in his/her duty to act professionally, when professional training has not been completed” (Provincial Court of Navarra, sec. 1.ª, 13/05/1998, EDJ 1998/11184).It is recognised that the conduct required of each professional in the case of resident physicians (MIR [Médico interno residente]) must be considered on a case-by-case basis. Thus, the Provincial Court of La Rioja resolves (Resolution 61/2004, 27/02/2004): “In relation to the conduct required of each professional, the liability of the resident doctor must be individually analysed.” Furthermore, “No one opposes residents accessing an operating room or performing a medical activity necessary for their training, but they must always act under the direct supervision of a specialist” (STSJ Galicia, 22/11/2000, EDJ 2000/66262).Resident doctors are restricted to providing supervised healthcare. Consequently, their duty of care is determined at all times by the instructions and the guardianship of those in charge of their supervision (Provincial Court of Huelva. Decree 44/2000 of 26/01/2000).Another issue is that, as they are temporary professionals, they can be abused and made to exceed their duties or hours. If this occurs, the resident must document these attitudes since they are actions that are not in accordance with ethics or the law, and always act conscientiously and for the benefit of the patient.Orders by phoneThese are not recommended, except to inform the patient that he/she should be evaluated before any diagnosis and treatment. In extreme cases, first aid procedures may be communicated followed by the indication of transport to a hospital. The nursing staff is obliged to record the therapeutic orders and their type, which, in turn, must be taken into account by the doctor.Virtual consultationsThese pose the problem that there is no medical or physical examination, only the anamnesis. In my opinion, in neurosurgery this represents a high-risk scenario. It should be noted that it is the system that imposes these consultations, since a face-to-face consultation always includes the personal examination of the patient. My recommendation to the professionals who perform them is that they include a safeguard clause by which they clearly establish that said consultation suffers from a lack of personal examination of the patient and, consequently, its results have a limited degree of certainty. This is so that the patient is aware of this situation and can take the actions he/she wishes to undergo said examination. This clause should also include the fact that it is the system that forces this type of consultation, since the Administration should guarantee that the medical procedure is carried out without limitations. If not, the Administration should be liable, not the physician, if problems arise.On-callWhatever the on-call system of an institution, both the professionals and the institution itself must establish standards of action that limit or prevent delays. This entails good emergency care services and communication and transfer systems for on call specialists.Some studies suggest that many consultations with specialists have shortcomings and it is often not clear who is responsible, the professional who calls or the specialist who answers<a class="elsevierStyleCrossRef" href="#bib0130">26</a>.On the other hand, the specialist who attends to the patient after a call must guarantee appropriate patient follow-up. The on-call mode does not imply that once the visit has been completed, the medical act has been completed, especially when it requires follow-up.It should also be borne in mind that the list of professionals and the on-call procedure are the responsibility of the hospital, not the doctor who calls them. Some health systems have certain specialties on the staff and not others. This is decided at the discretion of the institution and should be the responsibility of the institution.How to increase defensibilityProtocols and standards of careOne way to increase defensibility is to advance the establishment of standards of care. However, this also involves problems. For example, they have error rates, are changeable as they are subject to review, and include an interpretive component, since two experts may differ in their interpretation of Lex Artis in the same case.A good protocol should include the observed error rates even when strictly following the directions. We know that, even with the best protocol, 4% of coronary anginas remain undiagnosed. Consequently, protocols must be interpreted flexibly.It is also advisable to have what is known as “institutional or administrative clinical guidelines”, either from the hospital itself or from the locoregional healthcare setting. This makes it possible to adapt to the circumstances of each centre and provides a method to assess the actions according to the rules adopted by it.The value of protocols in malpractice cases has also been questioned. This is because all of them have been developed to support healthcare, not as an incriminating evaluation system, which can lead to a bias when using them for the latter purpose<a class="elsevierStyleCrossRef" href="#bib0135">27</a>.It has also been claimed that standards of care pose problems when evaluating neurosurgical cases, recommending that healthcare professionals refer to the scientific evidence available for each specific scenario rather than to a protocol<a class="elsevierStyleCrossRef" href="#bib0140">28</a>.It should be added that the protocols can also refer to health actions, such as changes in healthcare workload. Developing a checklist in these and other cases can be useful.Standards of care must also be based on cases that go wrong. This also involves publishing the so-called “black lists”, which is not very common in the literature. We recommend publishing these situations in legal medicine journals, since in Spain it will be forensic doctors who will assess many of these cases.Communicating or reporting deficienciesIf a deficiency is reported and a problem is later recorded, the defensibility of the physician to the detriment of the system is much greater than if it has not been reported.Guaranteeing the accreditation and continuous training of professionalsThe possibility of accrediting solid training and professional experience on the subject is an essential element. This work in public medicine falls to the system, and health administrations should be urged to guarantee continuous training of professionals.In particular, there is a lack of training in medical-legal issues in most specialties, so progress should be made in this field<a class="elsevierStyleCrossRef" href="#bib0145">29</a>.Adequate completion of the medical historyThis must be legible (at least by the doctor who has written it), complete, even at the risk that the accused is the person who writes the most. All parts of the history should be recorded, especially the medical history of the case. Low-quality or incomplete medical records influence judicial decisions in malpractice cases<a class="elsevierStyleCrossRef" href="#bib0150">30</a>. Emotional or derogatory comments (patient, medical) should not be made. Corrections need to be handled properly. If corrections are made, they must be done by annotations with the date, signature and addendum justifying the addition. Instructions of all kinds given to auxiliary personnel (including those made by telephone), as well as the results of the most significant examinations and tests, should be recorded.The medical history is an essential element in the defensibility of the physician. It is often the only defence, or the key to conviction.It has been said that the history is only as good as the professional who writes it and is also a guarantee of the credibility of the care provided.Informed consent (IC)Lack of informed consent is often seen by lawyers as synonymous with malpractice. But it has also been considered sufficient (in the absence of the IC document) to document in the annotations of the history that the information has been given, recording the patient's agreement with the proposed treatment.Although it is not mandatory to include atypical or exceptional risks in the information, there is a tendency to include in the IC document those that are relevant (e.g., stroke or death)<a class="elsevierStyleCrossRef" href="#bib0155">31</a>.Delegation in the patient information sheet by the physician is not acceptable, but the delivery of the IC document for reading and signing by the patient is acceptable, provided that sufficient information has been previously given by the doctor. It should not be forgotten that the information is verbal, and that the IC document is only a means, required by law, of documenting that the information provided is appropriate for the specific case.Yet even with the best information, there is no guarantee of understanding-recall by the patient, especially if significant time elapses<a class="elsevierStyleCrossRef" href="#bib0160">32</a>. This fact can help in the defensibility of some cases in the face of allegations of lack of information (there was no lack of information, but rather comprehension and recall deficits). We have already commented that only 43% of neurosurgical patients sufficiently understand the most relevant aspects of the process to be performed, and this percentage drops to 38.4% at six weeks in neurosurgery<a class="elsevierStyleCrossRef" href="#bib0090">18</a>. Similar data have been confirmed in other specialties<a class="elsevierStyleCrossRef" href="#bib0165">33</a>.Assessment of medical errorWho should assess these casesA big problem in this assessment is the issue of who does the assessing and who should do it.In Spain there is the figure of a forensic pathologist, who, as an official expert for the Administration of Justice, is systematically consulted by judges in criminal cases in order to determine whether there has been malpractice or not.However, generally speaking, the forensic pathologist is not an official specialist in the subject matter of the claim, and may also fall into a dogmatic approach to the matters, given his/her status as an official expert. Some argue that contamination can arise, with legal criteria interfering with the interpretation of the standards of care. On the other hand, this figure is a guarantee of impartiality who understands the language and legal issues that can help the judge to understand the case.For this reason, a model to be extended, in my opinion, is for the forensic pathologist to work in collaboration with specialty experts appointed by the scientific society or by medical associations.Regarding the expert witnesses (defence or prosecution), many scientific societies have established some requirements for proceeding in these cases, as well as some rules of conduct<a class="elsevierStyleCrossRef" href="#bib0170">34</a>. Experts must also conduct themselves in accordance with the ethical standards in their performance, which is considered a medical act<a class="elsevierStyleCrossRef" href="#bib0175">35</a>.Based on the recommendations, any expert who intends to intervene in cases of possible malpractice in neurosurgery should be required, at a minimum, to meet the following requirements<a class="elsevierStyleCrossRef" href="#bib0180">36</a>:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">•To hold the official title of corresponding specialist (neurosurgery in our case).</li><li class="elsevierStyleListItem" id="lsti0010">•To actively and primarily exercise said specialty at the time of the expert report.</li><li class="elsevierStyleListItem" id="lsti0015">•To have, and be able to prove, a qualification, familiarity and knowledge in the specific area of expertise.</li><li class="elsevierStyleListItem" id="lsti0020">•To have knowledge of the standards and available clinical evidence applicable to the specific case.</li><li class="elsevierStyleListItem" id="lsti0025">•To receive reasonable remuneration to cover the time and effort required. Compensation for contingency (depending on the outcome of the litigation) is unethical.</li><li class="elsevierStyleListItem" id="lsti0030">•To be prepared for his/her testimony to be submitted to peer review, that is, to a double review by other specialists not involved in the procedure.</li><li class="elsevierStyleListItem" id="lsti0035">•To always give a neutral, detailed and objective testimony, without excluding any relevant information.</li><li class="elsevierStyleListItem" id="lsti0040">•To comply with ethical standards.</li></ul>These last rules, according to the American Association of Neurological Surgeons (AANS), can be summarised as:<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0045">-Impartial evidence.</li><li class="elsevierStyleListItem" id="lsti0050">-Knowledge of the subject matter of expertise.</li><li class="elsevierStyleListItem" id="lsti0055">-Compensation for contingency (depending on the outcome of the process) must not be accepted.</li></ul>Regarding the figure of the specialist in the assessment of bodily harm, who in many cases intervenes in cases of negligence, it must be rejected, as several sentences have already established. This specialty does not appear on the list of official medical specialties, but rather concerns university master's degrees or similar degrees. Moreover, these professionals (with some exceptions) are not specialists in the specific matter that is the subject of the claim. It has also been suggested that there may be contamination with spurious criteria and a lack of training and/or expert activity, which means a reduction in their impartiality and, on occasions, in their qualification to act as experts.Post-claim attitudeThe following are general recommendations for the person accused of malpractice:<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0060">-Report it immediately to the insurance company.</li><li class="elsevierStyleListItem" id="lsti0065">-Maintain absolute confidentiality on the case.</li><li class="elsevierStyleListItem" id="lsti0070">-Keep al documentation safely (in some cases the history has disappeared).</li><li class="elsevierStyleListItem" id="lsti0075">-Participate in the defence. Highly recommended, including written descriptions, reports and evaluations of the conduct.</li><li class="elsevierStyleListItem" id="lsti0080">-It should not affect personal or professional life and daily work must carry on regardless. Seek help for this if necessary.</li><li class="elsevierStyleListItem" id="lsti0085">-Once the case is resolved, consider the possibility of proceeding against the complainant in cases of false claims or bad faith.</li></ul>ConclusionsThe dispersion of official data on claims due to lack of care suitability calls for the creation of a national central claims registry, since, otherwise, it is not possible to draw appropriate conclusions that allow for improvement of the quality of care in the event that individual or system deficiencies are found.In my opinion, the management of healthcare professionals in these situations should include a model that takes into account not only the defensibility in the event of a possible error or omission, but other aspects related to the reduction of litigation. The model that we propose, and that we call therapeutic, aims to bring together these two pillars of action in a single strategy to prevent failures and also so that the response to it, once elicited, is the fairest for both the professional and the patient.Conflicts of interestThe author has no conflicts of interest to declare." "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:3 [ "identificador" => "xres1641955" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1463828" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1641954" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1463829" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Litigability and defensibility" ] 6 => array:3 [ "identificador" => "sec0015" "titulo" => "How to reduce litigability" "secciones" => array:10 [ 0 => array:2 [ "identificador" => "sec0020" "titulo" => "Creating an enabling environment" ] 1 => array:2 [ "identificador" => "sec0025" "titulo" => "Dedication to information efforts" ] 2 => array:2 [ "identificador" => "sec0030" "titulo" => "Personalisation of care" ] 3 => array:2 [ "identificador" => "sec0035" "titulo" => "Promoting a good user-healthcare professional relationship (formerly called patient-doctor, or other healthcare professionals)" ] 4 => array:2 [ "identificador" => "sec0040" "titulo" => "Influencing the system" ] 5 => array:3 [ "identificador" => "sec0045" "titulo" => "Identifying and managing situations involving risk well" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0050" "titulo" => "First contact" ] 1 => array:2 [ "identificador" => "sec0055" "titulo" => "Change of healthcare workload" ] 2 => array:2 [ "identificador" => "sec0060" "titulo" => "Medical discharge" ] 3 => array:2 [ "identificador" => "sec0065" "titulo" => "Repeated requests for care" ] 4 => array:2 [ "identificador" => "sec0070" "titulo" => "Rejection of medical advice" ] ] ] 6 => array:2 [ "identificador" => "sec0075" "titulo" => "Resident performance" ] 7 => array:2 [ "identificador" => "sec0080" "titulo" => "Orders by phone" ] 8 => array:2 [ "identificador" => "sec0085" "titulo" => "Virtual consultations" ] 9 => array:2 [ "identificador" => "sec0090" "titulo" => "On-call" ] ] ] 7 => array:3 [ "identificador" => "sec0095" "titulo" => "How to increase defensibility" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0100" "titulo" => "Protocols and standards of care" ] 1 => array:2 [ "identificador" => "sec0105" "titulo" => "Communicating or reporting deficiencies" ] 2 => array:2 [ "identificador" => "sec0110" "titulo" => "Guaranteeing the accreditation and continuous training of professionals" ] 3 => array:2 [ "identificador" => "sec0115" "titulo" => "Adequate completion of the medical history" ] 4 => array:2 [ "identificador" => "sec0120" "titulo" => "Informed consent (IC)" ] ] ] 8 => array:3 [ "identificador" => "sec0125" "titulo" => "Assessment of medical error" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0130" "titulo" => "Who should assess these cases" ] 1 => array:2 [ "identificador" => "sec0135" "titulo" => "Post-claim attitude" ] ] ] 9 => array:2 [ "identificador" => "sec0140" "titulo" => "Conclusions" ] 10 => array:2 [ "identificador" => "sec0145" "titulo" => "Conflicts of interest" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2021-08-19" "fechaAceptado" => "2021-10-10" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1463828" "palabras" => array:5 [ 0 => "Liability" 1 => "Defensibility" 2 => "Legal" 3 => "Malpractice" 4 => "Claims" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1463829" "palabras" => array:5 [ 0 => "Litigabilidad" 1 => "Defendibilidad" 2 => "Legal" 3 => "Mala praxis" 4 => "Reclamaciones" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "Despite its indisputable importance, there are not many official data on claims for malpractice at the national level in Spain, mainly due to transfers from Health to the Autonomous Communities. This lack of unified information, together with other variables related to modern Healthcare Medicine (type of healthcare system, ethical aspects, consent, patients' rights, new technologies, etc.), complicates the healthcare professional's response to claims, and could not guarantee adequate protection of this against possible liability.This article analyzes the current situation in Spain and emphasizes aspects such as defensibility and liability in malpractice claims, taking as a model the Neurosurgery Specialty, one of the most prone to this type of situation.Prevention and action guidelines are offered, through a model aimed at reinforcing defensibility and reducing liability. This approach, which we call a “therapeutic model”, considers the problem analogously to a disease, providing the basis for its prevention and management.We believe that this approach can be useful both to the Neurosurgeon and to any healthcare provider at a time, such as today, when there is some confusion on these issues and some reluctance of insurance companies to provide coverage in some cases." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "Pese a su indiscutible importancia, no abundan los datos oficiales sobre reclamaciones por mala praxis asistencial a nivel nacional en España, debido, principalmente, a las transferencias de Sanidad a las Comunidades Autónomas. Esta falta de información unificada, junto a otras variables relacionadas con la moderna Medicina Asistencial (tipo de sistema sanitario, aspectos éticos, consentimiento, derechos de los pacientes, nuevas tecnologías, etc.), complica la respuesta del profesional sanitario ante las reclamaciones, y podría no garantizar una adecuada protección de este ante posibles denuncias.Este artículo analiza la situación actual en España y enfatiza aspectos como la defendibilidad y la litigabilidad en las reclamaciones por mala praxis, tomando como modelo la Especialidad de Neurocirugía, una de las más proclives a este tipo de situaciones.Se ofrecen líneas guía de prevención y actuación, mediante un modelo encaminado a reforzar la defendibilidad y reducir la litigabilidad. Dicho enfoque, al que llamamos “modelo terapéutico”, considera el problema análogamente a una enfermedad, proporcionando bases para su prevención y manejo.Creemos que este enfoque puede ser útil tanto al Neurocirujano como a cualquier sanitario en un momento, como el actual, en que existe cierta confusión sobre estos temas y también alguna reticencia de las Compañías aseguradoras a proporcionar cobertura en algunos casos." ] ] "NotaPie" => array:2 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Aso Escario J. Litigabilidad y defendibilidad en neurología y neurocirugía. Un modelo “terapéutico” para el manejo de reclamaciones por mala praxis asistencial. Neurocirugía. 2022;33:22–30." ] 1 => array:3 [ "etiqueta" => "1" "nota" => "Neurosurgeon, forensic doctor and specialist in Legal and Forensic Medicine." 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entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Waiting lists \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Waiting lists \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Waiting lists \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Waiting lists \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">General surgery \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">General surgery \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">General surgery \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">General surgery \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Emergency Department \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Emergency Department \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Emergency Department \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Emergency Department \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Traumatology \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Traumatology \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Traumatology \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Traumatology \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Obstetrics and gynaecology \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Obstetrics and gynaecology \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Obstetrics and gynaecology \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Obstetrics and gynaecology \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Oral and maxillofacial \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Oral and maxillofacial \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Oral and maxillofacial \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Oral and maxillofacial \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Medical transport and ambulances \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Medical transport and ambulances \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Medical transport and ambulances \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Medical transport and ambulances \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Anaesthesia and resuscitation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Oncology \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Anaesthesia and resuscitation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Anaesthesia and resuscitation \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Neurosurgery \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Anaesthesia and resuscitation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Oncology \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Cardiology \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Urology \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Cardiology \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Urology \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Oncology \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2797197.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Most reported departments and conditions (2017–2020)." ] ] 1 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">General \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Diagnostic delay \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Diagnostic error \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Undesired operative outcome \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Lack of informed consent (2%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Failure to provide information about the case \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Neurosurgical \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Complications of traumatic brain injury (TBI) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Delayed injuries (mainly haematomas) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Diffuse TBI without undue neuroradiological substrate \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Spinal surgery complications \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Vascular/visceral injuries \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Failed back surgery syndrome, level errors, etc. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Neural/dural injuries \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Other \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Errors/delays in diagnosis: tumour, subarachnoid haemorrhage, etc. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Herniation after lumbar puncture \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Neuroradiological procedures \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2797196.png" ] ] ] ] "descripcion" => array:1 [ "en" => "The most common causes of general claims and those in the specialty of neurosurgery." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:36 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "Arquillo Callet Begoña. 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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The latest official national data come from the INSALUD &#40;Instituto Nacional de la Salud &#91;National Institute of Health&#93;&#41; Inspectorate&#46; Between 1 January 1995 and 31 December&#44; 2000&#44; 2136 claims were registered&#46; In total&#44; 43 resulted in conviction and 298 were settled before going to trial<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a>&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">By specialty&#44; emergency medicine had the highest number of claims &#40;23&#46;8&#37;&#41;&#44; followed by obstetrics and gynaecology &#40;18&#46;2&#37;&#41;&#44; traumatology &#40;11&#46;2&#37;&#41;&#44; surgery and general medicine &#40;7&#37;&#41;&#44; ophthalmology &#40;4&#46;6&#37;&#41;&#44; neurosurgery &#40;4&#46;6&#37;&#41;&#44; cardiology &#40;3&#46;7&#37;&#41;&#44; paediatrics &#40;3&#46;7&#37;&#41;&#44; psychiatry &#40;2&#46;3&#37;&#41; and urology &#40;2&#46;3&#37;&#41;&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">In the database of the Barcelona College of Physicians&#44; traumatology was top in claims&#44; followed by gynaecology and obstetrics&#46; Neurosurgery ranks eighth most common<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a>&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Probably the only updated national data on the matter come from the Patient Ombudsman Association in its 2017&#8211;2020 reports<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#8211;7</span></a>&#46; The incidence by specialty is summarised in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46; Neurosurgery occupied ninth place in 2017&#44; but has disappeared from the top ten since 2018&#46; The reasons for claims are listed in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a><a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">Recently&#44; the United States has seen a reduction in the number of awarded claims&#44; with an increase in the average cost of compensation and in the frequency of compensation for catastrophic harm<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a>&#46; Among the reasons for this decline could be improvements in safety systems&#44; including checklists and protocols for changes in healthcare workload&#46; Furthermore&#44; the way in which institutions and insurers resolve claims could be an explanation if the institution considers it to be a problem with the system rather than the fault of a specific professional<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a>&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">These and other policies can mitigate the so-called &#8220;pena de banquillo &#91;bench penalty&#93;&#8221; &#40;or clinical-judicial syndrome&#41;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a>&#44; which makes the professional prone to errors and transforms their performance into defensive medicine&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">In this context&#44; we think that a unified approach is needed for an issue which&#44; as we see it&#44; is increasingly widespread&#46; However&#44; before we can present our model&#44; it is necessary to review two concepts rarely mentioned in the literature<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a>&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Litigability and defensibility</span><p id="par0040" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Litigability</span> is the likelihood that a claim for malpractice will be filed&#44; in any area &#40;administrative or judicial&#41;&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Defensibility</span> is the ability to defend the fact that the healthcare action is correct&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">For example&#44; neurosurgery would have a high litigability&#44; but its defensibility rate would also be very high &#40;90&#37;&#41;&#46; In contrast&#44; radiology would present poor litigability&#44; but its defensibility would be very low&#44; due to the high chance of documenting errors&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Litigability does not depend so much on technical aspects of healthcare as on ethical factors&#46; Elements such as a good user-healthcare professional relationship&#44; adequate social customs&#44; an &#8220;enabling&#8221; environment&#44; quality of information&#44; attitude of the healthcare team&#44; or the perception that the patient has of the quality of care&#44; are key factors in litigability<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13&#44;14</span></a>&#46; Along these lines&#44; for example&#44; is the fact that it is much higher for male doctors than their female counterparts<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a>&#46; Females would be better able to interact emotionally with the patient<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a>&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">In contrast&#44; defensibility does depend on the technical aspects of healthcare&#46; As such&#44; the degree of adjustment to the standard of care <span class="elsevierStyleItalic">&#40;Lex Artis &#91;standard of care&#93; ad hoc&#41;</span> reinforces or weakens defensibility&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">To understand the reasons behind claims&#44; prevent them and manage potential healthcare failures&#44; it is essential to develop protocols aimed not only at increasing defensibility but also at reducing litigability&#46; We will try to offer a model that serves both purposes&#46; This is what we call the &#8220;medical malpractice therapeutic model&#8221;&#44; based on applying preventive&#44; diagnostic and therapeutic tools as if it were a disease&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">How to reduce litigability</span><p id="par0070" class="elsevierStylePara elsevierViewall">We will highlight ethical elements and other non-technical healthcare factors&#46;</p><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Creating an enabling environment</span><p id="par0075" class="elsevierStylePara elsevierViewall">Several factors influence the patient&#39;s perception of care&#44; even before the doctor&#39;s intervention&#58; comfort&#44; the length of the wait&#44; the treatment given by the auxiliary staff&#44; the image of the environment &#40;rooms&#44; furniture&#44; cleanliness&#44; etc&#46;&#41;&#44; the appearance of the doctor and the auxiliary personnel&#44; etc&#46; Nobody goes to hospital for reasons other than illness&#44; and nobody expects the environment to contribute to increasing its effects&#44; but&#44; rather&#44; to mitigate them&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Dedication to information efforts</span><p id="par0080" class="elsevierStylePara elsevierViewall">This includes it being extended to family members to the extent that the patient allows it&#44; managing bad news or sensitive information well &#40;information in stages&#44; collaboration with other professionals in expert advice&#44; etc&#46;&#41;&#44; guaranteeing full&#44; accessible&#44; continuous information&#44; and dedicating the necessary time to it&#46; Maintaining internal consistency of the information and ensuring that the entire team is up to date with the information is another key factor&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">It has been calculated that 30&#37;&#8211;40&#37; of healthcare time is invested in information tasks and that claims increase inversely to the time spent on each consultation<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a>&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Administrations must keep in mind that the time required for healthcare is incompatible with many of the ratios that are considered normal or suitable in Spain&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Yet the best information is not a guarantee of adequate understanding by the patient&#46; In neurosurgery&#44; only about 43&#37; of the information is understood immediately after it is provided&#46; After six weeks&#44; this percentage drops to 38&#46;4&#37;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a>&#46; In other specialties&#44; 43&#46;6&#37; of the patients do not retain anything and 19&#46;6&#37; only retain 25&#37; of the information<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a>&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">These data indicate that&#44; in delayed complaints&#44; the versions of events offered by patients may not appropriately reflect the actual information provided at the time&#44; which is relevant to defensibility&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">In practice&#44; claims about problems related to informed consent are rare &#40;32&#37;&#41;&#46; However&#44; sometimes the doctor is not very accommodating to the patient or their relatives when providing information&#46; This fosters complaints&#46; Regarding deaths&#44; claims have been filed simply to obtain the medical history&#44; due to a lack of information about what happened and the doctors refusing to provide it&#46; Generally&#44; the explanations given in this situation and the death discharge report &#40;which is also a medical discharge&#41; can clarify many situations that&#44; otherwise&#44; would end up in court&#44; exceeding the administrative scope to which they could have been reduced&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Personalisation of care</span><p id="par0110" class="elsevierStylePara elsevierViewall">This should also be extended to the rest of the team members &#40;it is advisable to have a person in charge for each professional stratum&#41;&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Promoting a good user-healthcare professional relationship &#40;formerly called patient-doctor&#44; or other healthcare professionals&#41;</span><p id="par0115" class="elsevierStylePara elsevierViewall">The reification of healthcare is contrary to medical ethics&#46; The health worker is obliged to develop empathy&#44; be polite and courteous towards patients and their relatives&#46; Several studies have suggested that the deterioration of this relationship fosters claims<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a>&#46; The perception of a caring attitude or empathy for the patient reduces litigability&#46; There are a number of skills&#44; such as being able to understand and endorse the patient&#39;s perspective&#44; as well as reflecting on the patient&#39;s responses<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a>&#44; that work favourably in this regard&#46; Disparaging comments about the patient&#44; family members or other professionals have the opposite effect&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Influencing the system</span><p id="par0120" class="elsevierStylePara elsevierViewall">In 3&#37;&#8211;5&#37; of claims&#44; the outcome would have been the same in &#8220;the best hands and with the best care&#8221;&#46; However&#44; 95&#37; of cases are caused by a failure&#46; This deficiency is most often &#40;85&#37;&#41; due to the system and not the healthcare professional<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a>&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">A common cause of complaints is waiting lists&#46; These are caused by the system&#44; although the professional must warn the patient about the system and the risks of delay&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">The system has no criminal liability&#46; On this basis&#44; the undeniable responsibility that this has in cases of the poor operation of institutions is rarely realised either by the injured party or by the doctor involved&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">It is also much easier to place responsibility on a natural person rather than a legal entity&#44; since the latter is somewhat immeasurable&#46; This means that this burden of responsibility does not tend to be directed against the system&#46; A further pernicious consequence is that the healthcare deficiency may go uncorrected&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Normally&#44; we healthcare workers are in the best position to notice the deficiencies of the system and communicate its failures&#46; Unfortunately&#44; this is rare in practice&#46; On the one hand&#44; this is due to the tendency to make normal what might not be normal due to a misunderstood &#8220;force of habit&#46;&#8221; Another cause is the fear that the system will react with hostility against those who want to change it&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">It must be remembered that&#44; like any public worker&#44; healthcare professionals are obliged to report any defects they observe to their regulatory superior&#46; If this were done in practice&#44; it is likely that many claims would take a turn towards the imputation of the system or its administrative managers&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Recalling the legal aphorism &#8220;If it is not written down&#44; it does not exist&#44;&#8221; it is important to promote the culture of communication of deficiencies in writing&#46; Administrative managers&#44; for their part&#44; should not see these communications as a hostile action but rather as an obligation of the healthcare professional&#44; and channel it towards a risk management scenario rather than a protest&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">The involvement of the institutions is therefore crucial&#46; The development of communication and resolution strategies in the form of information programmes&#44; transparency&#44; apologising and compromising can reduce litigation<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> even after the adverse event has occurred<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a>&#44; although some do not agree that the so-called apology laws<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a>&#44; in isolation&#44; can lead to a lower incidence of claims<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a>&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Identifying and managing situations involving risk well</span><p id="par0160" class="elsevierStylePara elsevierViewall">There are various scenarios that carry a greater medical-legal risk&#46; To decrease litigability &#40;and also to increase defensibility&#41;&#44; an important task is to identify and manage them well&#46; These include the following&#58;</p><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">First contact</span><p id="par0165" class="elsevierStylePara elsevierViewall">Proper documentation of this is advised&#46; The role of emergency nursing history has been emphasised&#44; as it is often the best testimony to the patient&#39;s entry point into the system&#46; The collection of medical history is important&#44; since it is not uncommon for its lack of documentation to have dire consequences&#46; If the patient is referred from another centre&#44; any previous diagnosis should be collected&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Change of healthcare workload</span><p id="par0170" class="elsevierStylePara elsevierViewall">This change is usually imposed by the system&#46; For example&#44; patients who are entitled to care in another centre&#44; or transfers outside or within the hospital itself&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">Technically&#44; this involves a failure in the healthcare relationship&#44; which is why communication between the sender and the receiver is essential&#46; It is recommended to provide a detailed report of the patient&#39;s status at discharge&#44; preceded&#44; if necessary&#44; by telephone communication&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">The receiving department or professional should not assume that the patient&#39;s situation has not changed since the transfer&#44; so it is recommended to repeat the essential tests and&#44; of course&#44; the clinical examination&#46; In short&#44; it is recommended that the clinical history be taken again&#46; The recipient must see the case as new&#44; and the sender must guarantee a quality of care at the destination equal to or better than the prior care&#44; never worse&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Medical discharge</span><p id="par0185" class="elsevierStylePara elsevierViewall">It is mandatory that discharges&#44; whatever their type &#40;hospital&#44; death&#44; voluntary&#44; transfer&#44; etc&#46;&#41;&#44; are closed with an epicrisis&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">In addition to technical issues&#44; it is advisable to ensure the involvement of the family or take an interest in post-discharge circumstances &#40;care&#44; housing&#44; etc&#46;&#41; in sensitive cases&#44; or those with potential medical-legal risk&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">In situations carrying risk&#44; it is recommended that the discharge document be signed collectively &#40;sometimes with the inclusion of the centre director&#41; and that including reports from other professionals involved in the process be considered&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">There are some simple rules that can help manage the discharge process effectively&#46; One last look at the medical history before the patient leaves the department is highly recommended&#46; A last visit to the patient&#44; documenting his&#47;her condition at the time of discharge&#44; is also advisable&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">It is also recommended that the type of therapeutic instructions be recorded&#44; and it be specified as to whether they are &#8220;Mandated&#8221; or &#8220;If required&#8221;&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Repeated requests for care</span><p id="par0210" class="elsevierStylePara elsevierViewall">This usually involves a patient who has already been seen and who comes back for the same problem&#46; In the emergency department&#44; the &#8220;third time&#8221; rule is usually applied&#44; whereby a patient who comes to the emergency department for the third time within a short period of time &#40;a few days&#41; must be admitted for assessment&#46; This rule cannot be taken at face value&#44; but it does emphasise the risk of this situation and the need to study the case in detail&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Rejection of medical advice</span><p id="par0215" class="elsevierStylePara elsevierViewall">Consent is a contract between the patient and healthcare provider that can be broken by the former &#40;rejection of medical advice&#41; or by the latter &#40;in exceptional situations such as mistrust or refusal to follow instructions&#41;&#46;</p><p id="par0220" class="elsevierStylePara elsevierViewall">The Spanish Health Law &#40;Article 10&#44; Section 9&#41; establishes the right to &#8220;refuse treatment&#44; except in the cases specified in Section 6&#8221;&#46;</p><p id="par0225" class="elsevierStylePara elsevierViewall">It is essential that any refusal is documented in writing &#40;Law 41&#47;2002&#41;&#46; The law allows this record to be made by the physician through annotation in the clinical history in the event that the patient refuses to sign the refusal form that is usually provided by all centres&#46;</p></span></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Resident performance</span><p id="par0230" class="elsevierStylePara elsevierViewall">Residents are not immune from claims or convictions&#46; However&#44; since they must be supervised<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a>&#44; the tutor is answerable&#44; as long as there is no overreach&#46;</p><p id="par0235" class="elsevierStylePara elsevierViewall">Judgements in this regard assume that the resident acquires a progressive responsibility&#44; and that this depends on the evaluations carried out&#46; Thus&#44; the resident does not have a &#8220;position of guarantor and a duty to act on his&#47;her own and independently&#44; for which he&#47;she could be liable&#44; when in the case of the provision of a certain professional diligence&#44; it is necessary to have all the technical professional training&#44; having finished and completed it&#44; in order to be able to assess whether he&#47;she has failed in his&#47;her duty to act professionally&#44; when professional training has not been completed&#8221; &#40;Provincial Court of Navarra&#44; sec&#46; 1&#46;&#170;&#44; 13&#47;05&#47;1998&#44; EDJ 1998&#47;11184&#41;&#46;</p><p id="par0240" class="elsevierStylePara elsevierViewall">It is recognised that the conduct required of each professional in the case of resident physicians &#40;MIR &#91;M&#233;dico interno residente&#93;&#41; must be considered on a case-by-case basis&#46; Thus&#44; the Provincial Court of La Rioja resolves &#40;Resolution 61&#47;2004&#44; 27&#47;02&#47;2004&#41;&#58; &#8220;In relation to the conduct required of each professional&#44; the liability of the resident doctor must be individually analysed&#46;&#8221; Furthermore&#44; &#8220;No one opposes residents accessing an operating room or performing a medical activity necessary for their training&#44; but they must always act under the direct supervision of a specialist&#8221; &#40;STSJ Galicia&#44; 22&#47;11&#47;2000&#44; EDJ 2000&#47;66262&#41;&#46;</p><p id="par0245" class="elsevierStylePara elsevierViewall">Resident doctors are restricted to providing supervised healthcare&#46; Consequently&#44; their duty of care is determined at all times by the instructions and the guardianship of those in charge of their supervision &#40;Provincial Court of Huelva&#46; Decree 44&#47;2000 of 26&#47;01&#47;2000&#41;&#46;</p><p id="par0250" class="elsevierStylePara elsevierViewall">Another issue is that&#44; as they are temporary professionals&#44; they can be abused and made to exceed their duties or hours&#46; If this occurs&#44; the resident must document these attitudes since they are actions that are not in accordance with ethics or the law&#44; and always act conscientiously and for the benefit of the patient&#46;</p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Orders by phone</span><p id="par0255" class="elsevierStylePara elsevierViewall">These are not recommended&#44; except to inform the patient that he&#47;she should be evaluated before any diagnosis and treatment&#46; In extreme cases&#44; first aid procedures may be communicated followed by the indication of transport to a hospital&#46; The nursing staff is obliged to record the therapeutic orders and their type&#44; which&#44; in turn&#44; must be taken into account by the doctor&#46;</p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Virtual consultations</span><p id="par0260" class="elsevierStylePara elsevierViewall">These pose the problem that there is no medical or physical examination&#44; only the anamnesis&#46; In my opinion&#44; in neurosurgery this represents a high-risk scenario&#46; It should be noted that it is the system that imposes these consultations&#44; since a face-to-face consultation always includes the personal examination of the patient&#46; My recommendation to the professionals who perform them is that they include a safeguard clause by which they clearly establish that said consultation suffers from a lack of personal examination of the patient and&#44; consequently&#44; its results have a limited degree of certainty&#46; This is so that the patient is aware of this situation and can take the actions he&#47;she wishes to undergo said examination&#46; This clause should also include the fact that it is the system that forces this type of consultation&#44; since the Administration should guarantee that the medical procedure is carried out without limitations&#46; If not&#44; the Administration should be liable&#44; not the physician&#44; if problems arise&#46;</p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">On-call</span><p id="par0265" class="elsevierStylePara elsevierViewall">Whatever the on-call system of an institution&#44; both the professionals and the institution itself must establish standards of action that limit or prevent delays&#46; This entails good emergency care services and communication and transfer systems for on call specialists&#46;</p><p id="par0270" class="elsevierStylePara elsevierViewall">Some studies suggest that many consultations with specialists have shortcomings and it is often not clear who is responsible&#44; the professional who calls or the specialist who answers<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a>&#46;</p><p id="par0275" class="elsevierStylePara elsevierViewall">On the other hand&#44; the specialist who attends to the patient after a call must guarantee appropriate patient follow-up&#46; The on-call mode does not imply that once the visit has been completed&#44; the medical act has been completed&#44; especially when it requires follow-up&#46;</p><p id="par0280" class="elsevierStylePara elsevierViewall">It should also be borne in mind that the list of professionals and the on-call procedure are the responsibility of the hospital&#44; not the doctor who calls them&#46; Some health systems have certain specialties on the staff and not others&#46; This is decided at the discretion of the institution and should be the responsibility of the institution&#46;</p></span></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">How to increase defensibility</span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Protocols and standards of care</span><p id="par0285" class="elsevierStylePara elsevierViewall">One way to increase defensibility is to advance the establishment of standards of care&#46; However&#44; this also involves problems&#46; For example&#44; they have error rates&#44; are changeable as they are subject to review&#44; and include an interpretive component&#44; since two experts may differ in their interpretation of <span class="elsevierStyleItalic">Lex Artis</span> in the same case&#46;</p><p id="par0290" class="elsevierStylePara elsevierViewall">A good protocol should include the observed error rates even when strictly following the directions&#46; We know that&#44; even with the best protocol&#44; 4&#37; of coronary anginas remain undiagnosed&#46; Consequently&#44; protocols must be interpreted flexibly&#46;</p><p id="par0295" class="elsevierStylePara elsevierViewall">It is also advisable to have what is known as &#8220;institutional or administrative clinical guidelines&#8221;&#44; either from the hospital itself or from the locoregional healthcare setting&#46; This makes it possible to adapt to the circumstances of each centre and provides a method to assess the actions according to the rules adopted by it&#46;</p><p id="par0300" class="elsevierStylePara elsevierViewall">The value of protocols in malpractice cases has also been questioned&#46; This is because all of them have been developed to support healthcare&#44; not as an incriminating evaluation system&#44; which can lead to a bias when using them for the latter purpose<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a>&#46;</p><p id="par0305" class="elsevierStylePara elsevierViewall">It has also been claimed that standards of care pose problems when evaluating neurosurgical cases&#44; recommending that healthcare professionals refer to the scientific evidence available for each specific scenario rather than to a protocol<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a>&#46;</p><p id="par0310" class="elsevierStylePara elsevierViewall">It should be added that the protocols can also refer to health actions&#44; such as changes in healthcare workload&#46; Developing a checklist in these and other cases can be useful&#46;</p><p id="par0315" class="elsevierStylePara elsevierViewall">Standards of care must also be based on cases that go wrong&#46; This also involves publishing the so-called &#8220;black lists&#8221;&#44; which is not very common in the literature&#46; We recommend publishing these situations in legal medicine journals&#44; since in Spain it will be forensic doctors who will assess many of these cases&#46;</p></span><span id="sec0105" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Communicating or reporting deficiencies</span><p id="par0320" class="elsevierStylePara elsevierViewall">If a deficiency is reported and a problem is later recorded&#44; the defensibility of the physician to the detriment of the system is much greater than if it has not been reported&#46;</p></span><span id="sec0110" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Guaranteeing the accreditation and continuous training of professionals</span><p id="par0325" class="elsevierStylePara elsevierViewall">The possibility of accrediting solid training and professional experience on the subject is an essential element&#46; This work in public medicine falls to the system&#44; and health administrations should be urged to guarantee continuous training of professionals&#46;</p><p id="par0330" class="elsevierStylePara elsevierViewall">In particular&#44; there is a lack of training in medical-legal issues in most specialties&#44; so progress should be made in this field<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a>&#46;</p></span><span id="sec0115" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Adequate completion of the medical history</span><p id="par0335" class="elsevierStylePara elsevierViewall">This must be legible &#40;at least by the doctor who has written it&#41;&#44; complete&#44; even at the risk that the accused is the person who writes the most&#46; All parts of the history should be recorded&#44; especially the medical history of the case&#46; Low-quality or incomplete medical records influence judicial decisions in malpractice cases<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a>&#46; Emotional or derogatory comments &#40;patient&#44; medical&#41; should not be made&#46; Corrections need to be handled properly&#46; If corrections are made&#44; they must be done by annotations with the date&#44; signature and addendum justifying the addition&#46; Instructions of all kinds given to auxiliary personnel &#40;including those made by telephone&#41;&#44; as well as the results of the most significant examinations and tests&#44; should be recorded&#46;</p><p id="par0340" class="elsevierStylePara elsevierViewall">The medical history is an essential element in the defensibility of the physician&#46; It is often the only defence&#44; or the key to conviction&#46;</p><p id="par0345" class="elsevierStylePara elsevierViewall">It has been said that the history is only as good as the professional who writes it and is also a guarantee of the credibility of the care provided&#46;</p></span><span id="sec0120" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Informed consent &#40;IC&#41;</span><p id="par0350" class="elsevierStylePara elsevierViewall">Lack of informed consent is often seen by lawyers as synonymous with malpractice&#46; But it has also been considered sufficient &#40;in the absence of the IC document&#41; to document in the annotations of the history that the information has been given&#44; recording the patient&#39;s agreement with the proposed treatment&#46;</p><p id="par0355" class="elsevierStylePara elsevierViewall">Although it is not mandatory to include atypical or exceptional risks in the information&#44; there is a tendency to include in the IC document those that are relevant &#40;e&#46;g&#46;&#44; stroke or death&#41;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a>&#46;</p><p id="par0360" class="elsevierStylePara elsevierViewall">Delegation in the patient information sheet by the physician is not acceptable&#44; but the delivery of the IC document for reading and signing by the patient is acceptable&#44; provided that sufficient information has been previously given by the doctor&#46; It should not be forgotten that the information is verbal&#44; and that the IC document is only a means&#44; required by law&#44; of documenting that the information provided is appropriate for the specific case&#46;</p><p id="par0365" class="elsevierStylePara elsevierViewall">Yet even with the best information&#44; there is no guarantee of understanding-recall by the patient&#44; especially if significant time elapses<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a>&#46; This fact can help in the defensibility of some cases in the face of allegations of lack of information &#40;there was no lack of information&#44; but rather comprehension and recall deficits&#41;&#46; We have already commented that only 43&#37; of neurosurgical patients sufficiently understand the most relevant aspects of the process to be performed&#44; and this percentage drops to 38&#46;4&#37; at six weeks in neurosurgery<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a>&#46; Similar data have been confirmed in other specialties<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a>&#46;</p></span></span><span id="sec0125" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Assessment of medical error</span><span id="sec0130" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Who should assess these cases</span><p id="par0370" class="elsevierStylePara elsevierViewall">A big problem in this assessment is the issue of who does the assessing and who should do it&#46;</p><p id="par0375" class="elsevierStylePara elsevierViewall">In Spain there is the figure of a forensic pathologist&#44; who&#44; as an official expert for the Administration of Justice&#44; is systematically consulted by judges in criminal cases in order to determine whether there has been malpractice or not&#46;</p><p id="par0380" class="elsevierStylePara elsevierViewall">However&#44; generally speaking&#44; the forensic pathologist is not an official specialist in the subject matter of the claim&#44; and may also fall into a dogmatic approach to the matters&#44; given his&#47;her status as an official expert&#46; Some argue that contamination can arise&#44; with legal criteria interfering with the interpretation of the standards of care&#46; On the other hand&#44; this figure is a guarantee of impartiality who understands the language and legal issues that can help the judge to understand the case&#46;</p><p id="par0385" class="elsevierStylePara elsevierViewall">For this reason&#44; a model to be extended&#44; in my opinion&#44; is for the forensic pathologist to work in collaboration with specialty experts appointed by the scientific society or by medical associations&#46;</p><p id="par0390" class="elsevierStylePara elsevierViewall">Regarding the expert witnesses &#40;defence or prosecution&#41;&#44; many scientific societies have established some requirements for proceeding in these cases&#44; as well as some rules of conduct<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a>&#46; Experts must also conduct themselves in accordance with the ethical standards in their performance&#44; which is considered a medical act<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a>&#46;</p><p id="par0395" class="elsevierStylePara elsevierViewall">Based on the recommendations&#44; any expert who intends to intervene in cases of possible malpractice in neurosurgery should be required&#44; at a minimum&#44; to meet the following requirements<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a>&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">&#8226;</span><p id="par0400" class="elsevierStylePara elsevierViewall">To hold the official title of corresponding specialist &#40;neurosurgery in our case&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">&#8226;</span><p id="par0405" class="elsevierStylePara elsevierViewall">To actively and primarily exercise said specialty at the time of the expert report&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">&#8226;</span><p id="par0410" class="elsevierStylePara elsevierViewall">To have&#44; and be able to prove&#44; a qualification&#44; familiarity and knowledge in the specific area of expertise&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">&#8226;</span><p id="par0415" class="elsevierStylePara elsevierViewall">To have knowledge of the standards and available clinical evidence applicable to the specific case&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">&#8226;</span><p id="par0420" class="elsevierStylePara elsevierViewall">To receive reasonable remuneration to cover the time and effort required&#46; Compensation for contingency &#40;depending on the outcome of the litigation&#41; is unethical&#46;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">&#8226;</span><p id="par0425" class="elsevierStylePara elsevierViewall">To be prepared for his&#47;her testimony to be submitted to peer review&#44; that is&#44; to a double review by other specialists not involved in the procedure&#46;</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">&#8226;</span><p id="par0430" class="elsevierStylePara elsevierViewall">To always give a neutral&#44; detailed and objective testimony&#44; without excluding any relevant information&#46;</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">&#8226;</span><p id="par0435" class="elsevierStylePara elsevierViewall">To comply with ethical standards&#46;</p></li></ul></p><p id="par0440" class="elsevierStylePara elsevierViewall">These last rules&#44; according to the <span class="elsevierStyleItalic">American Association of Neurological Surgeons &#40;AANS&#41;</span>&#44; can be summarised as&#58;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">-</span><p id="par0445" class="elsevierStylePara elsevierViewall">Impartial evidence&#46;</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">-</span><p id="par0450" class="elsevierStylePara elsevierViewall">Knowledge of the subject matter of expertise&#46;</p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">-</span><p id="par0455" class="elsevierStylePara elsevierViewall">Compensation for contingency &#40;depending on the outcome of the process&#41; must not be accepted&#46;</p></li></ul></p><p id="par0460" class="elsevierStylePara elsevierViewall">Regarding the figure of the specialist in the assessment of bodily harm&#44; who in many cases intervenes in cases of negligence&#44; it must be rejected&#44; as several sentences have already established&#46; This specialty does not appear on the list of official medical specialties&#44; but rather concerns university master&#39;s degrees or similar degrees&#46; Moreover&#44; these professionals &#40;with some exceptions&#41; are not specialists in the specific matter that is the subject of the claim&#46; It has also been suggested that there may be contamination with spurious criteria and a lack of training and&#47;or expert activity&#44; which means a reduction in their impartiality and&#44; on occasions&#44; in their qualification to act as experts&#46;</p></span><span id="sec0135" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">Post-claim attitude</span><p id="par0465" class="elsevierStylePara elsevierViewall">The following are general recommendations for the person accused of malpractice&#58;<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">-</span><p id="par0470" class="elsevierStylePara elsevierViewall">Report it immediately to the insurance company&#46;</p></li><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">-</span><p id="par0475" class="elsevierStylePara elsevierViewall">Maintain absolute confidentiality on the case&#46;</p></li><li class="elsevierStyleListItem" id="lsti0070"><span class="elsevierStyleLabel">-</span><p id="par0480" class="elsevierStylePara elsevierViewall">Keep al documentation safely &#40;in some cases the history has disappeared&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0075"><span class="elsevierStyleLabel">-</span><p id="par0485" class="elsevierStylePara elsevierViewall">Participate in the defence&#46; Highly recommended&#44; including written descriptions&#44; reports and evaluations of the conduct&#46;</p></li><li class="elsevierStyleListItem" id="lsti0080"><span class="elsevierStyleLabel">-</span><p id="par0490" class="elsevierStylePara elsevierViewall">It should not affect personal or professional life and daily work must carry on regardless&#46; Seek help for this if necessary&#46;</p></li><li class="elsevierStyleListItem" id="lsti0085"><span class="elsevierStyleLabel">-</span><p id="par0495" class="elsevierStylePara elsevierViewall">Once the case is resolved&#44; consider the possibility of proceeding against the complainant in cases of false claims or bad faith&#46;</p></li></ul></p></span></span><span id="sec0140" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0160">Conclusions</span><p id="par0500" class="elsevierStylePara elsevierViewall">The dispersion of official data on claims due to lack of care suitability calls for the creation of a national central claims registry&#44; since&#44; otherwise&#44; it is not possible to draw appropriate conclusions that allow for improvement of the quality of care in the event that individual or system deficiencies are found&#46;</p><p id="par0505" class="elsevierStylePara elsevierViewall">In my opinion&#44; the management of healthcare professionals in these situations should include a model that takes into account not only the defensibility in the event of a possible error or omission&#44; but other aspects related to the reduction of litigation&#46; The model that we propose&#44; and that we call therapeutic&#44; aims to bring together these two pillars of action in a single strategy to prevent failures and also so that the response to it&#44; once elicited&#44; is the fairest for both the professional and the patient&#46;</p></span><span id="sec0145" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0165">Conflicts of interest</span><p id="par0510" class="elsevierStylePara elsevierViewall">The author has no conflicts of interest to declare&#46;</p></span></span>"
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          "titulo" => "Abstract"
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          "titulo" => "Keywords"
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          "titulo" => "Resumen"
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          "titulo" => "Palabras clave"
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        4 => array:2 [
          "identificador" => "sec0005"
          "titulo" => "Introduction"
        ]
        5 => array:2 [
          "identificador" => "sec0010"
          "titulo" => "Litigability and defensibility"
        ]
        6 => array:3 [
          "identificador" => "sec0015"
          "titulo" => "How to reduce litigability"
          "secciones" => array:10 [
            0 => array:2 [
              "identificador" => "sec0020"
              "titulo" => "Creating an enabling environment"
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            1 => array:2 [
              "identificador" => "sec0025"
              "titulo" => "Dedication to information efforts"
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            2 => array:2 [
              "identificador" => "sec0030"
              "titulo" => "Personalisation of care"
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            3 => array:2 [
              "identificador" => "sec0035"
              "titulo" => "Promoting a good user-healthcare professional relationship &#40;formerly called patient-doctor&#44; or other healthcare professionals&#41;"
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              "identificador" => "sec0040"
              "titulo" => "Influencing the system"
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            5 => array:3 [
              "identificador" => "sec0045"
              "titulo" => "Identifying and managing situations involving risk well"
              "secciones" => array:5 [
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                  "titulo" => "First contact"
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                1 => array:2 [
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                  "titulo" => "Change of healthcare workload"
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                2 => array:2 [
                  "identificador" => "sec0060"
                  "titulo" => "Medical discharge"
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                3 => array:2 [
                  "identificador" => "sec0065"
                  "titulo" => "Repeated requests for care"
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                4 => array:2 [
                  "identificador" => "sec0070"
                  "titulo" => "Rejection of medical advice"
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            6 => array:2 [
              "identificador" => "sec0075"
              "titulo" => "Resident performance"
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            7 => array:2 [
              "identificador" => "sec0080"
              "titulo" => "Orders by phone"
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            8 => array:2 [
              "identificador" => "sec0085"
              "titulo" => "Virtual consultations"
            ]
            9 => array:2 [
              "identificador" => "sec0090"
              "titulo" => "On-call"
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        7 => array:3 [
          "identificador" => "sec0095"
          "titulo" => "How to increase defensibility"
          "secciones" => array:5 [
            0 => array:2 [
              "identificador" => "sec0100"
              "titulo" => "Protocols and standards of care"
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            1 => array:2 [
              "identificador" => "sec0105"
              "titulo" => "Communicating or reporting deficiencies"
            ]
            2 => array:2 [
              "identificador" => "sec0110"
              "titulo" => "Guaranteeing the accreditation and continuous training of professionals"
            ]
            3 => array:2 [
              "identificador" => "sec0115"
              "titulo" => "Adequate completion of the medical history"
            ]
            4 => array:2 [
              "identificador" => "sec0120"
              "titulo" => "Informed consent &#40;IC&#41;"
            ]
          ]
        ]
        8 => array:3 [
          "identificador" => "sec0125"
          "titulo" => "Assessment of medical error"
          "secciones" => array:2 [
            0 => array:2 [
              "identificador" => "sec0130"
              "titulo" => "Who should assess these cases"
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            1 => array:2 [
              "identificador" => "sec0135"
              "titulo" => "Post-claim attitude"
            ]
          ]
        ]
        9 => array:2 [
          "identificador" => "sec0140"
          "titulo" => "Conclusions"
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        10 => array:2 [
          "identificador" => "sec0145"
          "titulo" => "Conflicts of interest"
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        11 => array:1 [
          "titulo" => "References"
        ]
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    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2021-08-19"
    "fechaAceptado" => "2021-10-10"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec1463828"
          "palabras" => array:5 [
            0 => "Liability"
            1 => "Defensibility"
            2 => "Legal"
            3 => "Malpractice"
            4 => "Claims"
          ]
        ]
      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec1463829"
          "palabras" => array:5 [
            0 => "Litigabilidad"
            1 => "Defendibilidad"
            2 => "Legal"
            3 => "Mala praxis"
            4 => "Reclamaciones"
          ]
        ]
      ]
    ]
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    "resumen" => array:2 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Despite its indisputable importance&#44; there are not many official data on claims for malpractice at the national level in Spain&#44; mainly due to transfers from Health to the Autonomous Communities&#46; This lack of unified information&#44; together with other variables related to modern Healthcare Medicine &#40;type of healthcare system&#44; ethical aspects&#44; consent&#44; patients&#39; rights&#44; new technologies&#44; etc&#46;&#41;&#44; complicates the healthcare professional&#39;s response to claims&#44; and could not guarantee adequate protection of this against possible liability&#46;</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">This article analyzes the current situation in Spain and emphasizes aspects such as defensibility and liability in malpractice claims&#44; taking as a model the Neurosurgery Specialty&#44; one of the most prone to this type of situation&#46;</p><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Prevention and action guidelines are offered&#44; through a model aimed at reinforcing defensibility and reducing liability&#46; This approach&#44; which we call a &#8220;therapeutic model&#8221;&#44; considers the problem analogously to a disease&#44; providing the basis for its prevention and management&#46;</p><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">We believe that this approach can be useful both to the Neurosurgeon and to any healthcare provider at a time&#44; such as today&#44; when there is some confusion on these issues and some reluctance of insurance companies to provide coverage in some cases&#46;</p></span>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Pese a su indiscutible importancia&#44; no abundan los datos oficiales sobre reclamaciones por mala praxis asistencial a nivel nacional en Espa&#241;a&#44; debido&#44; principalmente&#44; a las transferencias de Sanidad a las Comunidades Aut&#243;nomas&#46; Esta falta de informaci&#243;n unificada&#44; junto a otras variables relacionadas con la moderna Medicina Asistencial &#40;tipo de sistema sanitario&#44; aspectos &#233;ticos&#44; consentimiento&#44; derechos de los pacientes&#44; nuevas tecnolog&#237;as&#44; etc&#46;&#41;&#44; complica la respuesta del profesional sanitario ante las reclamaciones&#44; y podr&#237;a no garantizar una adecuada protecci&#243;n de este ante posibles denuncias&#46;</p><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Este art&#237;culo analiza la situaci&#243;n actual en Espa&#241;a y enfatiza aspectos como la defendibilidad y la litigabilidad en las reclamaciones por mala praxis&#44; tomando como modelo la Especialidad de Neurocirug&#237;a&#44; una de las m&#225;s proclives a este tipo de situaciones&#46;</p><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Se ofrecen l&#237;neas gu&#237;a de prevenci&#243;n y actuaci&#243;n&#44; mediante un modelo encaminado a reforzar la defendibilidad y reducir la litigabilidad&#46; Dicho enfoque&#44; al que llamamos &#8220;modelo terap&#233;utico&#8221;&#44; considera el problema an&#225;logamente a una enfermedad&#44; proporcionando bases para su prevenci&#243;n y manejo&#46;</p><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Creemos que este enfoque puede ser &#250;til tanto al Neurocirujano como a cualquier sanitario en un momento&#44; como el actual&#44; en que existe cierta confusi&#243;n sobre estos temas y tambi&#233;n alguna reticencia de las Compa&#241;&#237;as aseguradoras a proporcionar cobertura en algunos casos&#46;</p></span>"
      ]
    ]
    "NotaPie" => array:2 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Aso Escario J&#46; Litigabilidad y defendibilidad en neurolog&#237;a y neurocirug&#237;a&#46; Un modelo &#8220;terap&#233;utico&#8221; para el manejo de reclamaciones por mala praxis asistencial&#46; Neurocirug&#237;a&#46; 2022&#59;33&#58;22&#8211;30&#46;</p>"
      ]
      1 => array:3 [
        "etiqueta" => "1"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Neurosurgeon&#44; forensic doctor and specialist in Legal and Forensic Medicine&#46;</p>"
        "identificador" => "fn0005"
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    ]
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                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">2017&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">2018&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">2019&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">2020&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Waiting lists&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Waiting lists&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Waiting lists&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Waiting lists&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">General surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">General surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">General surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">General surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Emergency Department&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Emergency Department&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Emergency Department&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Emergency Department&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Traumatology&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Traumatology&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Traumatology&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Traumatology&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Obstetrics and gynaecology&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Obstetrics and gynaecology&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Obstetrics and gynaecology&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Obstetrics and gynaecology&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Oral and maxillofacial&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Oral and maxillofacial&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Oral and maxillofacial&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Oral and maxillofacial&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Medical transport and ambulances&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Medical transport and ambulances&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Medical transport and ambulances&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Medical transport and ambulances&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Anaesthesia and resuscitation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">Oncology&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Anaesthesia and resuscitation&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">Anaesthesia and resuscitation&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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