Patient safety and the cost of medical errors

Soham D Bhaduri

THE World Health Organisation (WHO) recently came out with a dismaying figure of 138 million — estimated to be the number of patients witnessing harm caused by medical errors every year in medium and low-economic status countries (including India).

A Harvard study of 2013 estimated that India witnessed about 52 lakh medical injury cases annually, amounting to around 3 million years of healthy life lost each year. Medical errors are the third leading cause of death in the US, and the figure was reckoned to be 4 lakh in 2013. Clearly, it is a formidable public health problem projecting considerable (wasteful) costs for the healthcare system. An analysis of this problem reveals a range of appalling gaps in our public health system.

A medical error implies an avoidable adverse effect of medical treatment accruing harm to a patient. This is largely due to procedures deviant from their appropriate course: from administering a wrong drug or wrong dosage; the use of unsterile equipment leading to iatrogenic infection; inadequate care of the bed-ridden causing bed sores; omissions as gross as operating upon the wrong limb. Medical error isn’t synonymous with doctor’s neglect, which denotes breach of the duty of care on his part. It includes the whole array of mistakes and errors of judgment often engendered by factors beyond the healthcare providers' control and notwithstanding enough care and competence.

Those medical errors stemming from negligence are liable for civil litigation. In India, these are often dealt with in consumer courts, unless the negligence is of criminal proportions. Malpractice litigation, therefore, offers a mode of redress to the victims. The same, however, has made for an inept tool for deterring medical errors and omissions. The consumer courts, initially conceived to ease and fast-track the disposal of consumer complaints (including medical services), have suffered from the same problems as the rest of the judiciary, including delay in processing of cases, pendency, staff shortage, and non-uniformity in compensation payouts. Proving medical negligence, which requires mobilising expert testimony against the accused to the court's satisfaction, is a weary task on the part of the injured party. But even otherwise, addressing the larger problem of medical errors through malpractice litigation is a flawed tactic. Apart from multiple deleterious effects such as wasteful costs; unnecessary hassles for doctors; and jeopardising the doctor-patient relationship — it is highly limited in its scope, even under ideal conditions, to spur downstream improvements in care quality. 

Herein comes the role of overarching regulation of all medical establishments, public and private, to ensure minimum standards of care — an area where we have a deplorable track record. While 50-odd laws exercise jurisdiction of some or the other form on medical practice in India, it was only in 2010 that a dedicated Central legislation to actively ‘regulate’ standards and quality of care, the Clinical Establishments Act (CEA), was brought. Even then, its implementation has been dismal and fraught with compromises. The national register under the CEA currently has only 23,183 clinical establishments; even as early as 2010, there were some 10.4 lakh private establishments in the country as per NSS 2010 estimates. Multiple parallel state-level laws with varying powers, and often doddering machinery and archaic provisions, continue to exist at varying degrees of under-enforcement.

Lack of standard protocols, overburdened staff, and inadequate infrastructure are some of the foremost factors contributing to medical mistakes. Little wonder, given our weak regulatory system, that these remain the blots on our healthcare. Some 227 standard treatment guidelines for diseases have been issued under the CEA, but a practical roadmap for ensuring their observance seems as farfetched as ever. Undue heterogeneity of practices and infrastructure among small and medium enterprises, and criminally unregulated work hours of residents in government hospitals, are frontline drivers of the menace of medical errors.

Weaving quality of care outcomes into the provider payment system can help improve the quality of care, as is practised in many advanced nations. The glaring absence of a true national health system, which could embrace the majority of care providers in its ambit, makes such provisions impossible to implement in India. Similarly, the publication of performance results of individual hospitals and practices, as has been conceived in the US, provides an incentive for institutions to monitor and improve their practices — though it has negative effects too. Institutional arrangements to learn and relearn from mistakes and modify practices remain vastly deficient in India.

The problem also boils down to medical education. Practical approach among emerging doctors remains largely deficient in most medical schools. Vital skills like basic and advanced life support receive little emphasis in medical schooling, and are largely learnt through courses offered and taken privately. Measures such as a competency-based medical curriculum and a national exit test have been proposed to overcome such shortcomings, although their current scope seems limited. Training programmes for rural medical officers in vital areas like emergency medicine are often a farce - conducted mainly for achieving targets on paper, with little attention to stringency, periodicity, and practical rigour and to ensuring attendance of participants. It has been widely proposed that courses in critical care for doctors, especially in rural areas and tier 2 and 3 cities, can greatly help improve care in the critical hour.

Medical errors as a public health problem are thus a manifestation of wider and deeper problems in the Indian healthcare system. While immediate measures along some of the problem lines can be conceived, anything short of a comprehensive upgrade of the healthcare system will fail to yield sustained and considerable dividends. The obtrusive picture of medical errors depicted by the WHO can provide us another opportunity to look afresh and reflect closely on a number of basic and long-standing questions facing us, like regulation and funding of healthcare.

The author is a physician and a healthcare commentator

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