Opinion Deadly errors

There is a thin line between adverse events,medical errors and negligence. For instance,if a drug reaction occurs after a medicine is prescribed,despite it being known that the patient is sensitive to it,the physician will be considered negligent. That said,it is often difficult to identify whether an adverse event is to be blamed on medical error,negligence,or neither. A medical error does not qualify as negligence unless the degree of error exceeds an accepted norm. If a patient has

a classic history of acute appendicitis,clinical evaluation had typical findings and laboratory tests were also corroborative,but the treating surgeon failed to diagnose appendicitis,it would be both an error in diagnosis and also a case of negligence. However,if the diagnosis was made but the appendix was normal on surgery,it would be regarded as an error in diagnosis but not negligence,because the surgeon had followed the accepted standard of care.

Take another case. A patient undergoes a contrast enhanced computerised tomography (CECT) of the abdomen. However,after the procedure,the patient’s renal function deteriorates. He develops contrast-induced renal toxicity and requires haemodialysis. This event is considered adverse but not due

to negligence,as contrast-induced renal toxicity is unpredictable and the procedure was done in

a standard fashion.

Now suppose a patient has pytreygium in his left eye. The surgeon successfully performs the operation. During the post- operative period,the patient consults the surgeon for irritation and redness of the eye. He is verbally told to continue Mitomycin C eye ointment,which the patient continues for longer than needed. Now,prolonged use of Mitomycin C leads to dryness and loss of vision. Such error amounts to limited medical negligence as the surgeon failed to put down in writing the dosage and duration.

Again,during a therapeutic abortion in the ninth week of pregnancy,the gynaecologist unknowingly perforates the patient’s uterine wall with a suction device and lacerates the colon. The patient reports severe abdominal pain

and vaginal bleeding. The gynaecologist ignores her symptoms and discharges her without evaluation. The patient comes back to emergency with faecal peritonitis,requiring multiple surgeries. Here,the fact that she had internal injury during the procedure may be regarded as an adverse event,but that her post-procedural symptoms were ignored amounts to medical negligence.

There is no authentic data published from India about the prevalence of medical errors, actual malpractice or carelessness across public and private healthcare providers. However,two US studies suggested that between 44,000 to 200,000 Americans die each year as a result of medical error. One can only make a wild guess about numbers here,in the absence of proper internal or external audit by hospitals. Medication-related errors occur frequently in hospitals and although not all result in actual harm,those that do are costly. It is vital to note,however,that the prosecution of medical malpractice cases — in addition to having a high likelihood of failure — can be extremely expensive,stressful and time-consuming. Even in the US,only 15 per cent of personal-injury lawsuits filed annually involve medical malpractice claims,and more than 80 per cent of those end with no payment.

In New Zealand,patients seek compensation for medical injuries not through malpractice suits as in the US,but through a no-fault compensation system. Injured patients receive government-funded compensation,in turn relinquishing

the right to sue for damages except in rare cases. The country’s Accident Compensation Corporation (ACC) offers distinct advantages over the much-maligned US tort law system.

It has produced more timely compensation to a greater number of patients,as well as more effective processes for resolving disputes. The system,funded through general taxation and an employer levy,is remarkably affordable.

Adverse events,clinical error and medical negligence are serious issues. As the boundary of knowledge expands,more and more adverse events will become preventable. However,strict enforcement of guidelines might be effective in streamlining the standard of care. The identification of negligent behaviour and institution of appropriate corrective or disciplinary action are equally important to reduce medical negligence.

A malpractice claim exists if a provider’s negligence causes injury or damages to a patient. However,experiencing a bad outcome isn’t always proof of medical negligence. Also,on occasion,healthcare providers will inform a patient that the person has received negligent medical care from a previous healthcare provider and will sometimes tell a patient that they,themselves,have made a mistake. Another motivating factor is a quick,honest “apology” that might prevent a future claim,or provide an opportunity for a settlement without litigation. Insurance companies typically want to settle with an injured person directly if they can,and this allows them to do so before the full extent of injuries is known,as well as preventing

the injured person from hiring an attorney who could increase the settlement value.

As medical professionals,there are a few things we can do. We must establish a national focus to create leadership,research,methods and protocols to enhance knowledge about safety. We must identify and learn from errors through mandatory as well as voluntary reporting efforts. We could raise safety standards by involving oversight organisations and professional groups. Creating safety systems in healthcare at the delivery level should be the ultimate priority.

The SC judgment,and the unprecedented compensation prescribed,could widen mistrust between patients and health providers,and make the practice of medicine even more expensive,given the threat of litigation. It would not help the

Indian healthcare system to go the American way. To prevent that,it might help to establish a nodal statutory body for patient safety,by an act of Parliament. It could set goals,track progress and report back. It could also develop comprehensive knowledge of common errors and communicate ways to avoid them.

We must use this moment to proactively address patient safety,without setting up an opposition between their interests and those of the medical professionals serving them.

The writer is director,AIIMS,Delhi

Mahesh C. Misra