Homicidios intencionales en la salud: Un tema huérfano de la seguridad asistencial

Carlos Vivas; Homero Bagnulo

doi:10.29193/RMU.37.3.9

Authors

Carlos Vivas Ministerio de Salud, Comisión Nacional de Seguridad del Paciente, Ex Miembro. Servicio Médico Integral, Cirujano Coloproctólogo. Magister en Dirección de Empresas de Salud. Fulbright Scholar
Homero Bagnulo Ministerio de Salud, Comisión Nacional de Seguridad del Paciente, Ex Presidente. Fondo Nacional de Recursos, Ex Presidente. Hospital Maciel, Centro de Cuidados Intensivos, Ex Director

DOI:

https://doi.org/10.29193/RMU.37.3.9

Keywords:

HEALTHCARE SERIAL MURDER, HOMICIDE, HEALTH PERSONNEL, INTENTIONAL DAMAGE, PATIENT SAFETY, SECURITY MEASURES

Abstract

Intentional homicides committed by health workers in the course of their duties are very rare events. Its importance resides in the fact that the structural and functional weaknesses of health systems are exposed through its analysis. Moreover, their harmful effects are not limited to the victims and their families, since the reliability of the health system as a whole is damaged. This article summarizes the characteristics of these attacks, emphasizing the strategies of healthcare security that can intercept offenders.

References

1) Lubaszka CK, Shon PC. Reconceptualizing the notion of victim selection, risk, and offender behavior in healthcare serial murders. J Crim Psychol 2013; 3(1):65-78.
2) Lubaszka CK, Shon PC, Hinch R. Healthcare serial killers as confidence men. J Investig Psych Offender Profil 2014; 1:1-28.
3) The Long-Term Care Homes Public Inquiry; Yorker BC. Expert report on safety and security of residents in the long-term care homes system. Ontario, 2018. Disponible en: https://longtermcareinquiry.ca/en/exhibits/ [Consulta: 23 junio 2019].
4) The Joint Commission. Summary data of sentinel events reviewed. Oakbrook Terrace (IL), 2021. Disponible en: https://www.jointcommission.org/-/media/tjc/documents/resources/patient-safety-topics/sentinel-event/summary-se-report-2020.pdf [Consulta: 23 junio 2019].
5) Sackman B, Vecchione M, Shmetterer J. Behind the murder curtain. New York: Post Hill, 2018:chap 22. [Documento de Kindle].
6) Niels Högel: German ex-nurse convicted of killing 85 patients. BBC News, 6 june 2019. Disponible en: https://www.bbc.com/news/world-europe-48539894 [Consulta: 28 febrero 2020].
7) United Kingdom. Department of Health. The shipman inquiry: the final report. 27 january 2005. Disponible en: https://webarchive.nationalarchives.gov.uk/20090808155110/http://www.the-shipman-inquiry.org.uk/reports.asp [Consulta: 13 agosto 2012].
8) Wolf ZR, Donohue-Smith M, Wolf KC. Nurses who murder or who are accused of murder. Int J Hum Caring 2019; 23(1):51-70.
9) Sackman B, Vecchione M, Shmetterer J. Behind the murder courtain. New York: Post Hill, 2018:chap 9. [Documento de Kindle].
10) Sackman B. When the ICU becomes a crime scene. Crit Care Nurs Q 2015; 38(1):30-5.
11) Yorker BC, Kizer KW, Lampe P, Forrest AR, Lannan JM, Russell DA. Serial murder by healthcare professionals. J Forensic Sci 2006; 51(6):136-271.
12) Gillesse EE. Report of the Public Inquiry into the Safety and Security of Residents in the Long-Term Care Homes System. A systemic inquiry into the offences. Ontario, 2019. v.2. Disponible en: http://longtermcareinquiry.ca/wp-content/uploads/LTCI_Final_Report_Volume2_e.pdf [Consulta: 23 junio 2019].
13) Yorker BC. The legal side: nurses accused of murder. Am J Nurs 1988; 88(10):1327-32.
14) Johnstone RE, Katz RL, Stanley TH. Homicides using muscle relaxants, opioids, and anesthetic drugs: anesthesiologist assistance in their investigation and prosecution. Anesthesiology 2011; 114(3):713-6.
15) Farrell M. Health-care serial poisoning. En: Farrell M. Criminology of serial poisoners. Palgrave Macmillan, 2018:93-114.
16) Graeber C. The good nurse: a true story of medicine, madness, and murder. New York: Hachette Book Group, 2013:chap 63. [Documento de Kindle].
17) Field J, Pearson A. Caring to death: the murder of patients by nurses. Int J Nurs Pract 2010; 16:301-9.
18) Beine KH. Homicides of patients in hospitals and nursing homes: a comparative analysis of case series. Int J Law Psychiatry 2003; 26:373-86.
19) Yardley E, Wilson D. In search of the ‘Angels of Death’: conceptualising the contemporary nurse healthcare serial killer. J Investig Psych Offender Profil 2016; 13:39-55.
20) Henriksen K, Dayton E. Organizational silence and hidden threats to patient safety. Health Serv Res 2006; 41(4 Pt 2):1539-54.
21) Bagnulo H, Vivas C. ¿Cómo evitar que se repita? Arch Med Interna 2012; 34(3):65-6.
22) Martin G, Ozieranski P, Willars J, Charles K, Minion J, McKee L, et al. Walkrounds in practice: corrupting or enhancing a quality improvement intervention? Jt Comm J Qual Patient Saf 2014; 40(7):303-10.
23) Bal G, David S, Sellier E, François P. Intérêt des revues de mortalité et de morbidité pour la formation des médecins et l’amélioration de la qualité et de la sécurité des soins: revue de la littérature. Presse Med 2010; 39(2):161-8.
24) de Wet C, Bowie P. The preliminary development and testing of a global trigger tool to detect error and patient harm in primary-care records. Postgrad Med J 2009; 85(1002): 176-80.
25) Wolf ZR, Hughes RG. Best practices to decrease infusion-associated medication errors. J Infus Nurs 2019; 42(4):183-92.
26) World Health Organization. Medication safety in high-risk situations. Technical Report. Geneva: WHO, 2019.
27) The Long-Term Care Homes Public Inquiry; Greenall J. Expert report on safety and security of medication use process in residents in the long-term care homes system. Ontario, 2018. Disponible en: https://longtermcareinquiry.ca/en/exhibits/ [Consulta: 23 junio 2019].