Medical error and negligence
By Prof. Susirith Mendis-April 12, 2016, 6:59 pm
"Twelve-year-old boy died of a toothache on Sunday."
Washington Post Staff Writer
Wednesday, February 28, 2007
The above news item continues: "For want of a dentist ……boy dies after bacteria from tooth spread to his brain. A routine, $80 tooth extraction might have saved him. If his mother had been insured. If his family had not lost its Medicaid. If Medicaid dentists weren’t so hard to find. After two brain operations and more than six weeks of hospital care, the boy died."
The above anecdote tells us about the whole world of patient safety and its myriad implications in a nutshell. I am writing this piece today because I happened to read with avid interest, my good teacher Prof. Carlo Fonseka’s article on "Dangerous Doctoring" in the ‘Sunday Island’ today (10.04.2016). I thought it might be relevant to add a little bit to it since the subject has been brought up by him.
Since I was concerned for a long time about the lack of vigilance of our medical professionals and the Sri Lanka Medical Association (SLMC) - of which I was a member for 10 years, and found how ineffectual it is in ensuring patient safety and patent rights - I made a point of talking about this aspect of medical care among my professionals friends and colleagues. The result was that I was invited to make Chief Guest and Keynote addresses by several medical professional associations. These included Sri Lanka College of Surgeons (SLCOS) on "Surgical Practice, Ethics and the Law"; Sri Lanka College of Obstetricians & Gynaecologists (SLCOG) on "Obstetric Practice, Ethics and the Law" and Sri Lanka Dental Association (SLDA) on "Dental Negligence and Legal Implications".
Thereat, among other things, I said the following:
It is ironic that, the better the standard of healthcare with advanced technology in a modern hospital setting, the more likely a doctor would be found to be negligent. The reports on the incidence of medical error, negligence and misadventure are increasing throughout the world. It is still the tip of the proverbial iceberg. Let me ask a few questions at the outset. Is this increase in incidence because (i) standards have deteriorated? (ii) more doctors are now less skillful? (iii) they are now more careless? (iv) lawyers like to make more money from doctors? (v) patients are more litigious? (vi) medical insurance companies are paying greater compensation? (vii) Or, like in cricket, the technology is exposing inherent mistakes and human errors of doctors?
Let us look at some subtle differences. Negligence is an act of commission or omission by a healthcare provider in which care provided deviates from accepted standards of practice in the medical community and causes injury or death to the patient. For negligence to be legally supported, there is the burden of proof on the victim (or the prosecution) to establish ‘duty of care’. If a breach of ‘duty of care’ is not established, negligence cannot be imputed to the doctor. Furthermore, a causal relationship between the breach of the duty and the damage caused to the patient has also to be established. Negligence can be of two kinds. Criminal Negligence that could lead to sentencing and imprisonment; and Medical (clinical) negligence that leads to damages being awarded.
As against that, there is Medical Misadventure or error or unexpected outcome during medical intervention leading to serious deleterious effect on the patient. If this is within the scope of natural probability, there is no case for negligence. Errors and Mistakes are adverse events that could be prevented given the current state of medical knowledge. But again, within the scope of the expertise, experience and expected knowledge of the doctor, it is accepted with, perhaps, an administrative and/or professional admonition or warning. An Adverse Event is defined as undesirable and unintentional, though not necessarily unexpected, results of medical treatment. An example of an adverse event is discomfort in an artificial joint that continues after the expected recovery period, or a chronic headache following a spinal tap. Adverse events should be reported in hospital audits. But it hardly ever happens in Sri Lanka. This is unfortunate because it’s the collection of such adverse events occurring worldwide that will ensure new evidence-based care in such situations.
To err is human
Here are some interesting statistics:
An average of 195,000 people in the USA died due to potentially preventable, in-hospital medical errors in each of the years 2000, 2001 and 2002, according to a study of 37 million patient records. (The Health Grades Patient Safety in American Hospitals study 2000-02).
According to Dr. Lucien Leape, the author of a Harvard study, the number of deaths from medical errors in hospitals in the US alone, account for the equivalent to the death toll from three jumbo jet crashes every two days. (Public Health Reports, 1999; 114: 302-317 July / August, 1999).
One in every 10 patients admitted to a hospital is the victim of at least one medical mistake. (National Public Radio (NPR) November 21, 2000)
More people die each year in the United States from medical errors than from highway accidents, breast cancer or AIDS, a federal advisory panel reported in 2010.
The report from the National Academy of Sciences’ Institute of Medicine cited studies showing between 44,000 and 98,000 people die each year because of mistakes by medical professionals. "That’s probably an underestimate for two reasons. One is, there are many different kinds oferrors we never learn about - even in retrospective studies - because they are never written down. Second, these studies did not include other areas of care like home care, nursing homes and ambulatory care centers." (Dr. Donald Berwick,in the famous "To Err Is Human" Reportof the Institute of Medicine, Washington DC, 1999).
In a later study, the authors claim that the numbers may be much higher –"between 210,000 and 440,000 patients each year who go to the hospital for care suffer some type of preventable harm that contributes to their death." (Journal of Patient Safety:September 2013 - Volume 9 - Issue 3 - p 122–128)
European data, mostly from European Union Member States, consistently show that medical errors and health-care related adverse events occur in 8% to 12% of hospitalizations. For example, the United Kingdom Department of Health, in its 2000 report - ‘An Organisation with a Memory’ - estimated about 850 000 adverse events a year - 10% of hospital admissions (WHO).
Doctor errors occur more frequently than patients realise.Most instances of doctor errors are not the result of intentional recklessness, but most doctor errors are easily preventable.Doctors are not infallible, no matter how much patients would like them to be.While doctors’ mistakes are not usually intentional, they typically occur when doctors fail to exercise the proper level of care and skill.
The situation developing in the UK with young doctors out on the streets protesting the Tory government’s new healthcare policy to reduce NHS expenditure by insisting on longer working hours for less pay, thanks to the ‘tax avoiding’ Cameron and his government, will inevitably increase ‘human error’ in doctor ‘decision-making’ as well as due to poorer ‘attention to duty’ by fatigued young doctors. Unfortunately, when doctors’ mistakes do happen, the consequences can be disastrous – even fatal. Also, unfortunately, the disaster and fatalities are not affecting the politicians making those anti-people decisions, but affects usually the poor and the unempowered.
What about the situation in Sri Lanka? There is a large body of ‘knowledge’ acquired from anecdotal narratives from patients, their relatives and also doctors (many of my students who are ethical doctors who suffer from pangs of conscience) who speak with us in strict confidence and anonymity on incidents of gross medical negligence in the Sri Lankan medical/healthcare settings. Some are horrendous stories that are clearly in the category of criminal negligence. These occur both in the State and private sectors. But there are no statistics available even on ‘Medical Errors in Sri Lanka’. The Annual Health Bulletin published by the Ministry of Health does not have a category under ‘Indoor morbidity and Mortality Reports’ on patient safety or medical errors. They are unlikely to have such a category for the foreseeable future.
Don’t misunderstand me. I pay tribute to the many doctors who serve their patients with due diligence, dedication and sacrifice. They are the strength and the backbone of our remarkable healthcare system that we have every right to be proud of. Nevertheless, we have much to put our house in order.
There is a veil of professional secrecy that shrouds these ‘dark medical phenomena’ in Sri Lanka. I believe that until such time, that we have the strength of our convictions and are able to rent this shroud asunder, and in spite of all our enviable health statistics, we will remain backward and in the backwoods within the comity of (to coin a term) truly ‘medically responsible’ nations of the world.
