Sunday, October 28, 2001		Keeping fit

Ways to minimise doctors’ errors
B.K. Sharma

EVEN under the best of circumstances and with all goodwill on the part of the doctor and the patient, some errors and misunderstandings are inevitable. Press as well as the electronic media have been highlighting the errors and what they consider gross negligence on the part of the doctor or the hospitals.

We are new to such complaints and legal action against the doctors. This is much more prevalent in western society, particularly in the USA.

There have been many thought-provoking studies in the epidemiology of medical errors. Only last year the British Medical Journal in one of its issues in March brought out a series of articles on the subject. In a famous and well- conducted study — The Harvard Study — Brennan and his colleagues studied the records of 51 acute care hospitals in New York consisting of over 30,000 patients. They found that in 3.7 per cent of admissions patients had suffered as a result of medical error resulting in prolonged stay in the hospital or disability. The disability was defined on a well-laid down criteria and not based on a frivolous complaint.

In a study of 28 hospitals in Australia and an analysis of over 14,000 patients, the rate of adverse events was even higher — to the extent of 16.6 per cent.

No such study is available from our own country. In public hospitals problems of poor staffing, infrastructure and over-crowding complicate the issue.

Everything that goes wrong is not an error or mistake on the part of the doctors or the institutions. When it comes to gross negligence (a wrong eye taken out or an opposite leg amputated) or gross ethical misconduct, there is very little to defend and this article is not intended towards that kind of errors.

But when it comes to the error of judgment or a matter of experience and unusual circumstances, a liberal benefit should be given to the doctor. In the medical jurisprudence it is a recognised principle that a doctor’s performance has to be judged in the context of his experience, his qualification, level of hospital and other circumstances in which he is working. In fact, the bottom line is that he or she should have acted as any reasonable person would have acted under those circumstances.

It needs to be recognised to begin with that although individuals can go wrong and make mistakes, but usually it is the total set up and circumstances that lead to mishaps. Those circumstances may be inbuilt in the system, in the complexity of the cases, facilities available and unusual circumstances prevailing at a given time. There are a large number of psychological and physiological factors responsible in individual cases.

At the level of hospital or the organisation, lack of a well-coordinated supply system, maintenance, proper house keeping, environmental facilities conducive to comfortable working (light, airconditioning, ventilation etc.), psychological encouragement and protection are the factors which can make all the difference.

Factors which are responsible in the individual patient conducive to mishap include:

• Emergency admission

• A complex illness

• Multiple illnesses or trauma

• Extreme of age

• Prolonged hospital stay

• Requirement of multiple drugs

• An uncooperative attitude

• Unusual reaction to drugs like allergies

• Toxic reactions.

Many of the factors mentioned above presume that the basic system of the hospital or a clinic is working reasonably well. Unfortunately, in India public hospitals and even private clinics, circumstances are not most favourable. It is a well-known fact how ill-equipped and poorly-staffed are our public hospitals where even the basic amenities of day to day registration, records, elementary investigations and even the basic drugs recommended by the WHO are not available.

The patient is sent for purchasing various articles almost the moment he arrives in the hospital.

Even in the national institutes which are expected to deliver the highest level of medical aid, the shortage and system faults are numerous. The purpose of this write-up is not to go into the genesis of their difficulties, but it is mentioned in the context of the errors or mishaps in these hospitals. Both the doctors and the hospitals should be judged in the context of demands on these hospitals. A very good example often highlighted in the Press of a non-working piece of equipment or lack of a particular therapeutic facility like the respirators.

The PGI Chandigarh for instance has increased respirators from 10 to nearly 50 in the last 10 years, yet this number may not be enough to look after the requirement of the entire five states surrounding the PGI. If the surrounding hospitals of these states do not offer these facilities, should the PGI be blamed when a dire emergency admitted is not given the respirator when it may be required?

The society and the consumer courts need to know the limitations of an individual doctor as well as the hospital.

This is not to suggest that there is no scope for improvement in the system. The doctors need to keep themselves updated in their professional knowledge for which the Govt of India is thinking of a recertification procedure every five years although it has not yet been made operative.

Formal and well-laid out procedures should be followed so that the:

• Omissions and commissions are fewer

• Good record keeping is of immense value

• The staff should be trained to use protocols and maintain records.

• Each incidence of mishap should be analysed dispassionately and system correction should be applied rather than blaming the individual who often becomes defensive.

• Periodic review of organisation and system should be done and changes made accordingly.

According to Dr Helmriech, the lessons, learnt from high-safety organisations like aviation, atomic reactors and the space programme, the emphasis should be on the inbuilt safety in the system and there should be no need to depend upon the performance of the individual alone.