Publicaciones de interés

Frecuencia EA en AP y hospitales en España

• Estudio nacional sobre los efectos adversos ligados a la hospitalización. ENEAS 2005 . Madrid: Ministerio de Sanidad y Consumo; 2006.

• Aranaz-Andrés JM, Aibar-Remón C, Vitaller-Murillo J, Ruiz-López P, Limón-Ramírez, Terol-García E, ENEAS work group. Incidence of adverse events related to health care in Spain: results of the Spanish National Study of Adverse Events . J Epidemiol Community Health. 2008;62(12):1022-9.

• Aranaz-Andrés JM, Aibar-Remón C, Vitaller-Burillo J, Requena-Puche J, Terol-García E, Kelley E, Gea-Velazquez de Castro MT, ENEAS work group. Impact and preventability of adverse events in Spanish public hospitals: results of the Spanish National Study of Adverse Events (ENEAS) . Int J Qual Health Care. 2009;21(6):408-14.

• Aranaz-Andrés JM, Limón R, Mira JJ, Aibar C, Gea MT, Agra Y, and the ENEAS Working Group. What makes hospitalized patients more vulnerable and increases their risk of experiencing an adverse event? Int J Qual Health Care. 2011; 23:705-11.

• Estudio APEAS. Estudio sobre la seguridad de los pacientes en atención primaria de salud . Madrid: Ministerio de Sanidad y Consumo; 2008.

• Aranaz J, Aibar C, Limon, Mira JJ, Vitaller J, Agra Y, Terol E. A study of the prevalence of adverse events in primary healthcare in Spain . Europ J Public Health. 2012; 22: 921-5.
• Aranaz Andrés JM, Limón Ramírez R, Aibar Remón C, Gea-Velázquez de Castro MT, Bolúmar F, Hernández-Aguado I, et al. Comparison of two methods to estimate adverse events in the IBEAS Study (Ibero-American study of adverse events): cross-sectional versus retrospective cohort design . BMJ Open. 2017;7:e016546.

Estudios, guías, regulaciones legales y memorias nacionales e internacionales en materia de eventos adversos y seguridad del paciente

• Agbabiaka TB, Lietz M, Mira JJ, Warner B. A literature-based economic evaluation of healthcare preventable adverse events in Europe . Int J Qual Health Care. 2016. 
• Catholic Healthcare Partners (CHP). Guidelines for Responding to Serious Adverse Events ; 2010.
• DECRETO 78/2016, de 17 de mayo, sobre medidas de seguridad de pacientes que reciban asistencia sanitaria en los centros y servicios sanitarios en Euskadi . Boletín Oficial del País Vasco N.º98, miércoles 25 de mayo de 2016.
• LEGGE 8 marzo 2017, n. 24. Disposizioni in materia di sicurezza delle cure e della persona assistita, nonche' in materia di responsabilita' professionale degli esercenti le professioni sanitarie. (17G00041) (GU Serie Generale n.64 del 17-03-2017).

• National Quality Forum (NQF). Serious Reportable Events In Healthcare - 2011 Update: A consensus report . Washington, DC: NQF; 2011.
• National Patient Safety Agency, National Health Service (NHS). The Incident Decision Tree . National Patient Safety Agency; 2004.
• National Patient Safety Agency; National Health Service (NHS). Medical error. What to do if things go wrong: a guide for juniors doctors . National Patient Safety Agency; 2010.
• Parliamentary and Health Service Ombudsman. Learning from mistakes: An investigation report by the Parliamentary and Health Service Ombudsman into how the NHS failed to properly investigate the death of a three-year old child . Parliamentary and Health Service Ombudsman; 2016.

• World Health Organization. World Health Alliance for Patient Safety, Forward Programme . Geneve: World Health Organization; 2004.

Estudios más citados sobre seguridad del paciente y sobre segundas y terceras víctimas, revisiones y estudios realizados en España hasta ahora

• Abd Elwahab S, Doherty E. What about doctors? The impact of medical errors . Surgeon. 2014;12:297-300.

• Aranaz JM, Mira JJ, Guilabert M, Herrero JF, Vitaller J y Grupo de Trabajo Segundas Víctimas. Repercusión de los eventos adversos en los profesionales sanitarios. Estudio sobre las segundas víctimas . Trauma Fund MAPFRE. 2013; 24: 54-60.

• Borrell-Carrió F, Páez Regadera C, Suñol Sala R,Orrego Villagan C, Gil Terrón N, Martí Nogués M. Errores clínicos y eventos adversos: percepción de los médicos de atención primaria . Aten Primaria. 2006;38:25-32.

• Brandom B, Callahan P, Micalizzi DN. What happens when things go wrong? Pediatric Anesthesia. 2011; 21: 730-6.

• Burlison JD, Scott SD, Browne EK, Thompson SG, Hoffman JM. The second victim experience and support tool: validation of an organizational resource for assessing second victim effects and the quality of support resources . J Patient Saf. 2014 [Epub ahead of print].

• Cobos-Vargas A, Pérez-Pérez P, Núñez-Núñez M, Casado-Fernández E, Bueno-Cavanillas A. Second Victim Support at the Core of Severe Adverse Event Investigation . Int J Environ Res Public Health. 2022;19:16850.
• Conway JB, Weingart S. Leadership: Assuring respect and compassion to clinicians involved in medical error . Swiss Medical Weekly. 2009;139(1–2):3.

• Denham C. TRUST: the 5 rights of the second victim . J Patient Saf. 2007;3(2):107-119.

• Dyer C. Bawa-Garba case has left profession shaken and stirred . BMJ. 2018;360:k456.
• Gerven EV, Seys D, Panella M, Sermeus W, Euwema M, Federico F, et al. Involvement of health-care professionals in an adverse event: the role of management in supporting their workforce . Pol Arch Med Wewn. 2014;124:313-20.

• Goldberg RM, Kuhn G, Andrew LB, Thomas HA. Coping with medical mistakes and errors in judgment . Ann Emerg Med 2002;39:287–92.
• Johannsson H, Rook W. Avoiding blame and liability is vital to learning from errors and engineering a safer NHS . BMJ. 2018;360:k447.

• Martens J, Van Gerven E, Lannoy K, Panella M, Euwema M, Sermeus W, et al. Serious reportable events within the inpatient mental health care: Impact on physicians and nurses . Rev Calid Asist. 2016;31:26-33.
• McCartney M. Margaret McCartney: Doctors and families must be able to work together for safer care . BMJ. 2018;360:k443.
• Mira JJ, Carrillo I, Lorenzo S, Ferrús L, Silvestre C, Pérez-Pérez P, et al. The aftermath of adverse events in Spanish primary care and hospital health professionals . BMC Health Services Research. 2015; 15:151.

• Mira JJ, Lorenzo S, Carrillo I, Ferrús L, Pérez P, Iglesias F, et al. Interventions in health organisations to reduce the impact of adverse events in second and third victims . BMC Health Services Research. 2015. 15:341.

• Oliver D. David Oliver: Should NHS doctors work in unsafe conditions? BMJ. 2018;360:k448. 
• Panella M, Rinaldi C, Leigheb F, Donnarumma C, Kul S, Vanhaecht K, et al. The determinants of defensive medicine in Italian hospitals: The impact of being a second victim . Rev Calid Asist. 2016;31:20-5.
• Panella M, Rinaldi C, Vanhaecht K, Donnarumma C, Tozzi Q, Di Stanislao F. Second victims of medical errors: a systematic review of the literature. Ig Sanita Pubbl. 2014;70:9-28.

• Parand A, Dopson S, Renz A, Vincent Ch. The role of hospital managers in quality and patient safety: a systematic review . BMJ Open. 2014;4:e005055.

• Pratt SD, Jachna BR. Care of the clinician after an adverse event . International J Obstetric Anesthesia. 2015; 24, 54-63.

• Pratt S, Kenney L, Scott SD, Wu AW. How to develop a second victim support program: a toolkit for health care organizations . Jt Comm J Qual Patient Saf. 2012;38:235-40.
• Rinaldi C, Leigheb F, Vanhaecht K, Donnarumma C, Panella M. Becoming a "second victim" in health care: Pathway of recovery after adverse event . Rev Calid Asist. 2016;31:11-9. 

• Saura-Llamas J, Martínez-Pastor A, Leal-Hernández M, Gómez-Portela J. Percepción de los residentes de medicina familiar sobre sus errores clínicos tras dos años de formación . SEMERGEN. 2011; 37:280-286.

• Schwappach D, Boluarte TA. The emotional impact of medical error involvement on physicians: a call for leadership and organisational accountability . Swiss Medical Weekly. 2008; October: 1-7.

• Scott S, Hirschinger L, Cox K, McCoig M, Brandt J, Hall L. The natural history of recovery for the healthcare provider ‘‘second victim’’ after adverse patient events . Qual Saf Health Care. 2009;18:325–30.

• Scott SD, Hirschinger LE, Cox KR, McCoig M, Hahn-Cover K, et al. Caring for our own: deploying a systemwide second victim rapid response team . Jt Comm J Qual Patient Saf. 2010;36:233-40.

• Seys D, Scott S, Wu A, Van Gerven E, Vleugels A, Euwema M, Panella M, Conway J, Sermeus W, Vanhaecht K. Supporting involved health care professionals (second victims) following an adverse health event: a literature review . Int J Nurs Stud. 2013;50:678-87.

• Seys D, Wu AW, Van Gerven E, Vleugels A, Euwema M, Panella M, et al. Health care professionals as second victims after adverse events: A systematic review . Eval Health Prof. 2013;36(2):135-62.

• Sirriyeh R, Lawton R, Gardner P, Armitage G. Coping with medical error: a systematic review of papers to assess the effects of involvement in medical errors on healthcare professionals’ psychological well-being . Qual Saf Health Care. 2010;18:746–52.
• Van Gerven E, Bruyneel L, Panella M, Euwema M, Sermeus W, Vanhaecht K. Psychological impact and recovery after involvement in a patient safety incident: a repeated measures analysis . BMJ Open. 2016;6:e011403.
• Van Gerven E, Deweer D, Scott SD, Panella M, Euwema M, Sermeus W, et al. Personal, situational and organizational aspects that influence the impact of patient safety incidents: A qualitative study . Rev Calid Asist. 2016;31:34-46.
• Van Gerven E, Vander Elst T, Vandenbroeck S, Dierickx S, Euwema M, Sermeus W, et al. Increased Risk of Burnout for Physicians and Nurses Involved in a Patient Safety Incident . Med Care. 2016;54:937-43.

• Vanhaecht K, Seys D, Russotto S, Strametz R, Mira J, Sigurgeirsdóttir S, Wu AW, Põlluste K, Popovici DG, Sfetcu R, Kurt S, Panella M on behalf of European Researchers’ Network Working on Second Victims (ERNST). An Evidence and Consensus-Based Definition of Second Victim: A Strategic Topic in Healthcare Quality, Patient Safety, Person-Centeredness and Human Resource Management . Int J Environ Res Public Health. 2022;19:16869. 
• Waterman AD, Garbutt J, Hazel E, Dunagan WC, Levinson W, Fraser VJ, Gallagher TH. The emotional impact of medical errors on practicing physicians in the United States and Canada . Jt Comm J Qual Patient Saf. 2007;33:467–76.

• White AA, Waterman A, McCotter P, Boyle D, Gallagher TH. Supporting health care workers after medical error: considerations for healthcare leaders . J Clin Outcomes Management. 2008; 15: 240-7.

• Wu AW. Medical error: the second victim . BMJ. 2000; 320:726-7.

Estudios recientes y de revisión sobre enfoque Open Disclosure

• Brok DM, Quella A, Lipira L, Lu DW, Gallagher TH. Physician assistants and the disclosure of medical error . Acad Med. 2014;89:858-62.

• Etchegaray JM, Gallagher TH, Bell SK, Dunlap B, Thomas EJ. Error disclosure: a new domain for safety culture assessment . BMJ Qual Saf. 2012; 21:594-9.

• Fallowfield L. Communication with patients after errors . Journal of Health Services Research & Policy. 2010;15 Suppl 1: 56-9.

• Hannawa AF. What constitutes "competent error disclosure"? Insights from a national focus group study in Switzerland . Swiss Med Wkly. 2017;147:w14427. 
• Helmchen LA, Richards MR, McDonald TB. How does routine disclosure of medical error affect patients’ propensity to sue and their assessment of provider quality? Evidence from survey data . Med Care. 2010; 48: 955-61.

• Kachalia A, Kaufman SR, Boothman R, Anderson S, Welch K, Saint S, et al. Liability claims and costs before and after implementation of a medical error disclosure program . Ann Intern Med. 2010;153:213-21.

• Kim CW, Myung SJ, Eo EK, Chang Y. Improving disclosure of medical error through educational program as a first step toward patient safety . BMC Med Educ. 2017;17:52.
• Lipira LE, Gallagher TH. Disclosure of adverse events and errors in surgical care: challenges and strategies for improvement . World J Surg. 2014;38:1614-21.

• Loren DJ, Garbutt J, Dunagan WC,Bommarito KM, Ebers AG, Levinson W, Waterman AD, Fraser VJ, Summy EA, Gallagher TH. Risk managers, physicians, and disclosure of harmful medical errors . Jt Comm J Qual Patient Saf. 2010;36:101-8.

• Lu DW, Guenther E, Wesley A, Gallagher Th. Disclosure of Harmful Medical Errors in Out-of-Hospital Care . Ann Emerg Med. 2012; 21: 215-21.

• Martín-Delgado MC, Fernández-Maillo M, Bañeres-Amella J, Campillo-Artero C, Cabré-Pericas L, Anglés-Coll R, et al. Conferencia de consenso sobre información de eventos adversos a pacientes y familiares . Rev Calid Asist. 2013;28:381-9.
• Mastroianni AC, Mello MM, Sommer S, Hardy M, Gallagher TH. The flaws in state “apology” and “disclosure” laws dilute their intended impact on malpractice suits . Health Aff (Millwood). 2010;29:1611-9.

• Mazor KM, Simon SR, Gurwitz JH. Communicating with patients about medical errors. A review of the literature . Arch Intern Med. 2004;164:1690-7.
• Mazor K, Roblin DW, Greene SM, Fouayzi H, Gallagher TH. Primary care physicians' willingness to disclose oncology errors involving multiple providers to patients . BMJ Qual Saf. 2016;25:787-95.

• Mira JJ, Lorenzo S, en nombre del Grupo de Investigación en Segundas Víctimas. Algo no estamos haciendo bien cuando informamos a los/las pacientes tras un evento adverso . Gac Sanit. 2015 [en prensa] doi: http://dx.doi.org/10.1016/j.gaceta.2015.04.004

• O'Connor E, Coates HM, Yardley IE, Wu AW. Disclosure of patient safety incidents: a comprehensive review . Int J Qual Health Care. 2010;22:371-9.

• Raemer DB, Locke S, Walzer TB, Gardner R, Baer L, Simon R. Rapid Learning of Adverse Medical Event Disclosure and Apology . J Patient Saf. 2014 [Epub ahead of print]

• Shapiro J, Whittemore A, Tsen LC. Instituting a culture of professionalism: the establishment of a center for professionalism and peer support . Jt Comm J Qual Patient Saf. 2014;40:168-77.

• Wu A, Boyle DJ, Wallace G, Mazor KM. Disclosure of adverse events in the United States and Canada: an update, and a proposed framework for improvement . J Public Health Res. 2013; 2: e32: 187-93.

• Wu AW, McCay L, Levinson W, Iedema R, Wallace G, Boyle DJ, McDonald TB, Bismark MM, Kraman SS, Forbes E, Conway JB, Gallagher TH. Disclosing Adverse Events to Patients: International Norms and Trends . J Patient Saf. 2014 [Epub ahead of print]
• Yürür G, Ramirez Valdez KP. Disclosure of Medical Errors: A Literature Review and the Situation in Turkey . Reports in Advances of Physical Sciences. 2017;2:1-25.