MEDICAL (MEDICAL) ERRORS.
THE PROBLEM OF IATROGENIC DISEASES
Questions for the lesson:
1. Damage to the health (or death) of the patient as a result of medical activities. Definition of medical error. Types and sources of medical errors and measures to prevent them. Attitude to medical errors. Responsibility of medical workers.
2. Medical negligence and poor outcome. The reasons for the increase in the number of complaints from the population about the negligent attitude of doctors to their duties and ways to reduce the number of these complaints (Statement of the WMA, 1992). Professional crime in the field of medical activity. Responsibility of medical workers.
3. Iatrogenic diseases: classification, causes, ways of elimination, prevention. Informational iatrogenics. Diseases caused by the action of a medical worker. Organization of medical care in the light of iatrogenic prevention.
• September 1992 Original: English, French
STATEMENT ON NEGLIGENT ATTITUDE OF DOCTORS TO THEIR DUTIES
Adopted by the 44th World Medical Assembly, Marbella, Spain, September 1992
In countries where medical negligence lawsuits are common, national medical associations are already looking for solutions to this problem. National medical associations, in whose countries such cases are relatively rare, should also be aware of the circumstances that are accompanied by an increase in the number of complaints against physicians.
In this “Statement”, the World Medical Association informs the national medical associations of the facts and sources of complaints about the negligent attitude of doctors to their duties. Legislative norms, traditions and the economic situation of each country, of course, determine the priorities of the individual points of this “Statement” for each national medical association. However, the WMA believes that it will be of interest to any national association.
1. An increase in the number of complaints about the negligent attitude of doctors to their duties may be due to:
a) Increasing professional knowledge and improving medical technology, which allows physicians to undertake medical interventions that were not possible in the past, and this implies an increase in risk.
b) Imposing on doctors the obligation to provide medical care to fit into a certain limited amount.
c) A mistaken confusion between the right to receive health care (which is possible) and the right to achieve and maintain health (which cannot be guaranteed).
d) Incitement by the media of distrust of doctors, calling into question their qualifications, knowledge and behavior, which encourages patients to file complaints against doctors.
e) The side effects of the “defensive stance” taken by medical professionals in connection with the increase in the number of lawsuits.
2. It is necessary to distinguish between “a negligent attitude of a doctor to his duties” and “an unfavorable outcome of the disease that occurred in the process of providing medical care through no fault of the doctor.
a) Medical malpractice should be understood as the inability to perform standard medical interventions for a given patient condition, lack of qualification or negligence in the treatment of the patient, which caused direct damage to the patient.
b) Unforeseen damage incurred in the course of treatment, which is not the result of a lack of qualifications of the attending physician, is an adverse outcome that occurred in the course of medical care, and should not involve the liability of the physician.
3. Compensation for damage to injured patients should be determined by law – separately for cases of negligent attitude of doctors to their duties and – for cases of an unfavorable outcome that occurred in the process of providing medical care.
a) The society should determine whether the patient is entitled to compensation for damages in cases of an unfavorable outcome that occurred through no fault of the doctor in the process of providing medical care, and, if this right is recognized, from what sources compensation should be made. The socio-economic situation of the country and its legislation determine the availability and volume of appropriate funds from which the necessary payments are made, and to which the doctor has no relation.
b) The procedure for establishing the fact of a doctor’s negligence in his duties and the amount of compensation to the patient in cases where the fact of negligence is established are determined by law.
4. National medical associations should analyze the possibility of the following forms of activity aimed at ensuring parity between the doctor and the patient:
a) Education programs that inform the general public about the risks associated with modern methods of treatment, as well as medical education programs that explain the essence of “informed informed consent” and teach how to obtain it.
b) educational programs that expose the limits of medical possibilities in conditions of limited funding.
c) Educational general medical programs in schools and other public institutions.
d) Improving the level and quality of medical education with an emphasis on the clinical qualification of physicians.
e) Development and implementation of programs aimed at improving the quality of medical services.
f) Establishing a policy for those doctors whose qualifications are deemed insufficient. Provision should be made for the temporary deprivation of such doctors of the right to practice and the establishment of appropriate retraining systems. Informing the public and governments about the negative social consequences of the “defensive attitude” of medical professionals (reinsurance with excessive research, avoidance of “difficult cases”, refusal of young doctors to specialize in those areas of medicine that are associated with high risk).
g) Informing the public about the possibility of incurring unforeseen damage in the course of treatment, the infliction of which is in no way connected with a lack of qualification or with the negligence of a doctor, and therefore does not involve his responsibility.
h) Legal protection of physicians in the event of a patient suffering unforeseen damage through no fault of the physician.
i) Contribute to the development of laws and regulations governing the filing and resolution of “medical malpractice” claims.
j) Active opposition to the arbitrary interpretation of the concept of “medical malpractice” by both lawyers and legislators.
k) Introduction of out-of-court forms of malpractice litigation, such as arbitration.
l) Promotion of occupational risk insurance for physicians. Private practitioners must enter into such agreements themselves, and if the doctor is employed, then this is the responsibility of his employer.
m) Participation in decision-making on the payment of compensation to patients who have suffered damage during treatment that is not related to medical negligence.
MEDICAL ERRORS AND DOCTOR’S CONSCIENCE: A EXCURSION TO HISTORY
OF DOMESTIC MEDICINE OF THE XIX — BEGINNING OF THE XX CENTURY 
V. I. Borodulin, V. M. Verbitsky, Yu. Yu. Kvaskova
The crisis of medicine in the USSR, as obvious as its numerous local achievements, became the subject of not only scientific discussions, but also a wide discussion in the general press. Among the root causes of the crisis, as a rule, there is also a sharp drop in morality in the medical environment. Naive calls to form morality with the help of the “Doctor’s Oath” are noticeably outdated, since it is now clear to everyone that morality is formed not on the basis of calls, oaths and exhortations, but on the basis of traditions. inherent in a given society, and the direct influence of the social environment.
The socio-psychological attitudes in society that developed in the 1980s are well known and are not the subject of this study. The authors set themselves a different task: using well-known historical examples to reconstruct the unwritten code of medical honor that guided university professors in the late 19th and early 20th centuries, considering it in relation to the problem of a doctor’s attitude to his medical errors.
The traditions of domestic clinical medicine in this matter date back to the great domestic doctor, scientist and citizen N. I. Pirogov, who devoted a whole book to the review and analysis of errors in his medical practice – the famous Annals of the Derpt Clinic. “We should consider ourselves thrice happy,” writes N. I. Pirogov in the preface to the second edition of the Annals, “if we manage to overcome this or that difficulty in using the rule of medical art to a certain extent, comprehend and overcome the rooted prejudice, expand for our companions the narrow path leading to the truth. But this can be achieved, in my opinion, only if we carefully study the mistakes we made in the practice of practical medicine – moreover, elevate their knowledge to a special branch of science! Proceeding from the conviction, based on the study of the spirit of our art, that “we must make mistakes,” practical mistakes, including the grossest ones, must be regarded not as something shameful and punishable, but as something inevitable. One must hasten to admit one’s mistakes to one’s comrades and, above all, to comprehend the mechanism of mistakes. I admit that this is a labyrinth, the exits from which are closed by prejudices, vanity, ignorance; but a holy love for science, and therefore for truth, will find its guiding thread.”
Pirogov was guided by this principle throughout his life, persistently instilling it in his students and followers. Many domestic doctors, who considered themselves Pirogov’s students, preserved in their professional activities, among others, this Pirogov tradition. Consider, for example, how it manifested itself in the practice of the outstanding domestic obstetrician-gynecologist L. Ya. Krassovsky.
The young woman died 40 hours after the excision of a giant ovarian cyst performed by A. Ya. Krassovsky. During the autopsy, performed by the no less famous pathologist N. M. Rudnev, it turned out that a sponge tampon had been left in the peritoneal cavity, which, apparently, could be at least one of the causes of death. A. Ya. Krassovsky considered it his duty to describe this case in the smallest detail in a specially dedicated article, publishing it on the pages of the very popular medical journal Medical Bulletin. “Under such circumstances,” writes A. Ya. Krassovsky, “as well as in other accidental surgical cases, the position of the surgeon is extremely unenviable: his friends in science, who understand the possibility of such failures, treat him with sympathy; others and. unfortunately, sometimes comrades laugh at him and refer the case to the discussion of incompetent judges in this special case. In my extreme conviction, such cases should not be hidden, but they should be clarified and jointly take care of measures to prevent them in the future.
A. Ya. Krassovsky carefully examines the whole mechanism of the mistake made, trying to answer the following questions: I. When and how did the sponge get into the abdominal cavity? 2. Have proper precautions been taken to ensure that the weight of the sponge is removed from the abdomen in time? 3. To what extent could the sponge be the cause of the unfortunate outcome of the operation? 4. What measures should be taken to avoid similar cases in the future? Based on this sad experience, the scientist formulated a clear list of rules, the observance of which would avoid the risk of accidentally leaving sponges in the abdominal cavity after the completion of surgery. So, he recommended counting the sponges before and after the operation, as well as tying long ribbons to them.
Did the famous St. Petersburg professor, maestro, head of the Department of Obstetrics and Women’s Diseases of the Medico-Surgical Academy have reason to fear that this publication would damage his authority? Undoubtedly. Krassovsky was already reproached for the high mortality rate during operations. But he nevertheless chose this particular path, considering it the only possible one for an honest doctor and researcher. He taught this to students and young doctors, urging them never to be ashamed to publicly express failures and mistakes, both former and occurring again, without leaving, however, without a critical review of one or the other. Only in this way can conscientiousness in medical practice be developed in the younger generation and the principles of charlatanism be removed.
Numerous memoirs and other sources testify that the public analysis of one’s medical mistakes for leading professors was the rule rather than the exception, was included in the code of medical honor, and was used as an important element of the pedagogical process. Such an analysis was often associated with severe emotional reactions, with a sense of personal guilt that could not be corrected, wounded by the vanity of a recognized master of diagnostics with an imperative sense of duty that did not allow evading an unpleasant discussion. The severity of the emotional experience can be seen from the well-known example of a diagnostic error by V. P. Obraztsov, one of the most talented Russian therapists. Let us cite the testimony of A. A. Rosnovsky, who studied at Kiev University in 1910-1916.
“Somehow Prof. VP Obraztsov completely devoted two or three lectures to the analysis of one seriously ill patient with a very complex picture of the disease. Having examined the patient in detail and subjected to a deep analysis of the whole picture of the disease, the professor ended these lectures with his characteristic words: “So, on the basis of all the data we have received, we have the right to conclude that in this case we can most likely assume …” Further followed by a diagnosis. The patient died after some time. At that moment, when the clinic was informed that the autopsy of this patient had begun at the Department of Pathological Anatomy, I, along with some comrades, was just working in the laboratory (we were obliged to personally do all the analyzes of the patients supervised by us).
Together with the doctors of the clinic, we hurried to see this autopsy. Soon V.P. Obraztsov also appeared in the morgue. By chance, I had to stand behind his broad back and follow everything that happened from behind his shoulder. The autopsy was performed by a very strict teacher, prof. VN Konstantinovich is a student of the outstanding scientist prof. Vysokovich.
In the course of the autopsy, a rather significant discrepancy between the clinical and pathoanatomical diagnosis was determined, as prof. Konstantinovich with a known dose of gloating and told those present. Accidentally raising his eyes to standing in front of me, Prof. Obraztsov, I was surprised to notice that his neck, the back of his head, and then his entire head, began to blush deeply. And when he turned to the exit, we were literally frightened: his face turned dark crimson.
The next day, according to the schedule, there was another lecture by Prof. Obraztsova. As always, according to routine, before the start of it, the organs of the deceased patient were delivered from the morgue on enameled plates. As always, our calm and stately professor entered the audience. And for two whole hours his penetrating, scrupulous analysis of the causes of the diagnostic errors discovered at the autopsy continued. This extremely frank, objective, highly self-critical analysis made an indelible impression on all of us. All this was done so sincerely, intelligently, instructively that in our eyes the authority of our beloved teacher, one of our idols of that time, increased even more, even stronger. And then for the first time I personally realized the full depth of the proud words of one of the brilliant surgeons of the last century T. Billroth: Only the weak in spirit, boastful talkers and tired of life are afraid to speak openly about the mistakes they have made. Whoever feels the strength in himself to do better, he does not feel fear of the consciousness of his mistake.
Sometimes the moral conflict in the soul of a doctor who made a serious mistake with fatal consequences for the patient reached the point of a serious personal tragedy, which in some cases ended in suicide of doctors. Let us dwell in more detail on one of these cases, the suicide of a talented professor – surgeon of the St. Petersburg Military Medical Academy S.P. Kolomnin, which happened on November 11, 1886 after an unsuccessful operation that led to the death of the patient.
In connection with a rectal ulcer (presumably of tuberculous etiology), curettage was carried out with a sharp spoon, followed by cauterization under conditions of anesthesin with cocaine in the form of an enema 4 times, 6 grains each. At the same time, the professor noted that this dose is half that used by French colleagues in similar operations. The groans of the patient testified to an insufficient dose. Approximately 45 min. after the operation, which was successful, Kolomnin proceeded to bypass the patients, and the patient began to have “seizures”: a weakened pulse, difficulty breathing, “blue face and hands. S. P. Kolomnin announced that the patient had been poisoned and, after consulting with Professor Sushchinsky, took a number of urgent medical measures (faradization, artificial respiration, subcutaneous injection of ether, injection of aniline into a vein, tracheotomy, inhalation of amyl nitrite, stimulating enemas), but to no avail: the patient died 3 hours after the operation.At autopsy, the diagnosis of cocaine poisoning was confirmed.
With the use of anesthesia, Kolomnin had difficulties from the very beginning: he found that the patient’s heart was out of order and chose not chloroform, but cocaine. According to the story of S.P. Botkin, the dose of the latter caused a dispute between Kolomnin and prof. Sushchinsky, who considered 2 grains to be the maximum dose. Kolomnin objected to him, relying on the experience of using cocaine in European clinics reflected in the literature – in the amount of 6 to 80 and even 96 grains. Being careful, he, as we know, limited himself to 25 grains and failed. The issue of dosing cocaine at that time was insufficiently studied and, according to the fair remark of Botkin, anyone could make a mistake here. But the original, different, mistake led to a tragic result – Kolomnin felt and understood this. Rather, to drown out this feeling, he went to Botkin with a pile of books and spent evenings with Morozov’s assistant watching foreign publications “regarding this ill-fated operation.”
. The fact is that the diagnosis of tuberculosis in the section was not confirmed. The students who were present at the examination of the patient even before she got an appointment with Kolomnin published symptoms that spoke in favor of a disease that was not too flattering for a woman (for which they were reproached by their comrades and the editorial staff of the Vrach magazine, which did not find it convenient to publish the alleged diagnosis of syphilis). They considered an increase in lymph nodes to be one of his symptoms, while Kolomnin, according to Botkin, attributed this symptom to manifestations of tuberculosis. “I blame myself more and more for the wrong diagnosis,” he told Botkin, “the diagnosis of tuberculosis was not confirmed. I didn’t have to do the operation and the patient would still be alive. Despite the fact that it’s not my fault, at times it seems to me that I killed her.” “I have a conscience, I am my own judge,” he replied to the persuasion of his comrades not to attach much importance to what had happened.
The highest decency, an exaggerated sense of duty were the most characteristic features of the moral character of S. P. Kolomnin. According to the recollections of colleagues and friends, he combined them with high professionalism. His crystal honesty and nobility have become a legend. Being an example of selflessness and devotion to the medical profession for colleagues, a standard of justice for students, Kolomnin was unusually attentive to patients, often helped them financially, knew how to encourage and reassure. He deserved the kindest reviews of domestic servants. From numerous press reports about funeral services for the late professor and memoirs, we learn that not only professors, but also students came to see him off on his last journey (they, including the sons of S. P. Botkin, carried the coffin, and in 1887 were going to publish a report on the activities of the department headed by Kolomnin during the period of his management), as well as many patients. Many wreaths were laid and many speeches were made, and their main motive was admiration for the honor and conscience of the deceased.
At the same time, the nature of the event itself and the circumstances of the life of the deceased, his condition in the period preceding the suicide, inevitably prompted an autographic analysis of this emergency. “Before the ill-fated operation,” recalls A. Falkenberg, “only three surgical interventions performed by Kolomnin ended in death. After the third case, when chloroform poisoning was the cause of death, the professor said, “One more unsuccessful operation, and I will shoot myself.” With regard to any operation as an intellectual and moral catastrophe, with an undoubted foreboding of it as a fatal inevitability, in this state of mind (“clouding of the mind”) the price of mistakes became more and more expensive and the price of a human, in this case, one’s own life became more insignificant. A contemporary recalls with what composure Kolomnin, lecturing on field surgery, noted the advantage of a Smith and Wesson revolver in suicide (later he would use this particular brand of pistol). It seems that readiness for an early transition to another world has always existed in the professor’s subconscious as the reverse side of a skeptical pessimistic attitude towards being and self as a possible way out of the conflict between the needs of the individual and activity. With extreme impressionability and periodic depressive states noted by many contemporaries, Kolomnin could use this outlet at any of the critical moments of his life. It was precisely such a moment that came for him on November 6, 1886. In any case, S. P. Botkin, who observed Kolomnin from the time of the operation until the fateful November 11, adhered to this point of view. Botkin argued that Kolomnin’s suicide could only be explained by severe internal suffering without sleep, without food – his nerves could not withstand such oppression.
What did contemporaries see behind Kolomnin’s suicide? “The entire press is filled with both truth and lies about this terrible catastrophe,” said V. Popov, a colleague of the deceased, in his farewell speech. For some, it was an example of an honest trial of oneself. Others found this deed deplorable, the result of unfavorable circumstances and pathological features of the suicide’s personality. Still others saw here a noble desire to give a useful lesson to a cruel mocking society, or, conversely, a manifestation of cowardice that demoralizes society. In the same way as the reasons that caused the death of this person, so the image of his personality as a whole, becoming the subject of general, including philistine, attention and even a role model, was essentially distorted, sometimes reduced to a level close to the level of understanding. and the tastes of the crowd.
Let us give two characteristic examples of the attitude of the medical community to the ethical problem that has arisen. V. A. Manassein, editor of the Vrach magazine, who was called the judge of honor of the entire medical class, defending the memory of the deceased from idle speculation and unfair condemnations, published sympathetic and reverent reviews about Kolomnin in the polemic with Novosti in the spirit of the farewell speeches of his colleagues.
Fundamentally different was the position of M. M. Manaseina, a well-known physician-writer (until 1879, the wife of V. A. Manassein). Actively communicating with student youth, she saw in “the incongruous rash applause that currently surrounds Professor Kolomnin’s suicide” as a demoralizing beginning for students and society as a whole, because young people were now free to think that suicide is a feat worthy of all respect. Filled with indignation over this, M. M. Manasseina, in a letter to K.P. Pobedonostsev, referring to whose authority she hoped to restore Christian morality, clearly sinned against the truth when she pathetically sharpened the question: “A man who was considered an ordinary surgeon, an unsuccessful professor during his lifetime, is now exalted as a hero, almost a genius, only because, contrary to the laws of religion and morality, he raised his hand against himself? , and now even he, the representative of the highest authority, bowed before the heroism of suicide, ”these words were said to me about two hours ago by a young doctor who had recently completed the course.”
The polemical enumeration in the quoted letter is obvious. At the same time, despite the extreme position of the author of the letter, there is also a grain of truth in it. In the act of S. P. Kolomnin, the tradition of uncompromising responsibility of the doctor in matters of duty found a vivid expression. But this act meant not a constructive, but a dead end development of the problem of medical errors. The extreme individualism of the professor, his free disposal of his life, could not but cause a rebuff from those who recognized such a right only for the Creator. Turning to the authority of conservative forces (in the person of Pobedonostsev), M.M. Manasseina tried in essence to convince the medical community that the duty of a doctor is to face his own mistakes with calm courage and bear responsibility for them before God and people.
There is no reason to conclude from the cases described and similar to them that in case of any serious professional failure, the doctor of that time subjected it to self-critical analysis, and his moral torment reached the degree of an irreparable personal tragedy. It happened differently, and with no less famous doctors. So, in the same 1870, when Krassovsky described his unsuccessful operation, Professor of Kharkov University I.P. mentioned three failures. At the same time, he reported that in one of the unsuccessful cases, an “incomplete ovariotomy” was performed, i.e. the ovarian cyst was opened, its purulent contents were removed, and the edges of the incision were sutured to the edges of the incision of the abdominal integuments. The patient survived only 7 days after the operation. The cause of death was not specified.
Some time later, in the same Medical Bulletin, a rather angry article by Lazarevich’s colleague at Kharkov University, the eminent pathologist D. Lyambl, appears, in which the protocol of the autopsy of this particular patient, carried out by the author in the presence of I. P. Lazarevich, other professors and students, is given. . “There was no ovariotomy, neither complete nor incomplete,” Lambl writes with a certain dose of sarcasm, “instead of a cyst, it turned out to be purulent inflammation of the peritoneum.” In other words, instead of the cyst wall, the surgeon excised a sheet of peritoneum, which ultimately led to the sad outcome of the operation. “In the reality of the data presented,” writes D. Lambl, “everyone present at the autopsy could be convinced, and especially Messrs. Lazarevich and Kremyansky. who, together with me, once again examined the preparation taken from the corpse after the autopsy. The author rightly reproaches I. P. Lazarevich not for a mistake, but for an unreliable description of the case.
Here we see another ethical problem: the relationship between the clinician and the pathologist. At the same time, in modern practice, as the prominent Soviet pathologist D.S. Sarkisov, “the latter in his activity begins to move away from his traditional role of an interlocutor and clinician’s assistant, turning into a kind of overseer, not only looking for failures in the diagnosis of a cure, but also advertising them …”. However, this is a topic for another study.
The examples cited here from domestic clinical practice of the late 19th and early 20th centuries indicate that both in case of medical errors and in other situations involving “the concepts of honor, conscience, duty, one could always find well-known cases of polar behavior of different doctors in similar professional situations. The question, in our opinion, is what exactly is accepted by the community of doctors as a moral norm, and what is considered as a deviation from it, which deviations the community is ready to recognize as acceptable (the conditional limit of the norm), and which ones it resolutely rejects as incompatible with morality.
Fundamentals of the legislation of the Russian Federation
on the protection of the health of citizens of July 22, 1993 N 5487-1
(as amended March 7, 2005) (excerpts)
Responsibility for causing harm to the health of citizens
Article 66. Grounds for compensation for harm caused to the health of citizens
In cases of causing harm to the health of citizens, the perpetrators are obliged to compensate the victims for damage in the amount and in the manner established by the legislation of the Russian Federation.
Responsibility for harm to the health of citizens caused by a minor or a person recognized as legally incompetent in accordance with the procedure established by law arises in accordance with the legislation of the Russian Federation.
Harm caused to the health of citizens as a result of pollution of the natural environment is compensated by the state, legal entity or individual who caused the harm, in the manner prescribed by the legislation of the Russian Federation.
Funds spent on the provision of medical care to citizens who have suffered from unlawful actions are recovered from enterprises, institutions, organizations responsible for the harm caused to the health of citizens, in favor of institutions of the state or municipal health care system that incurred the costs, or in favor of institutions of the private health care system, if treatment was carried out in institutions of the private health system.
Persons who have jointly caused harm to the health of citizens shall be jointly and severally liable for damages.
When harm is caused to the health of citizens by minors, compensation for damage is carried out by their parents or persons replacing them, and in the event of harm to the health of citizens by persons recognized as legally incompetent in the manner prescribed by law, compensation for damage is carried out at the expense of the state in accordance with the legislation of the Russian Federation.
The damage subject to compensation is determined in accordance with the procedure established by the legislation of the Russian Federation.
Article 68. Responsibility of medical and pharmaceutical workers for violation of the rights of citizens in the field of healthcare
In the event of a violation of the rights of citizens in the field of health care due to the unfair performance of their professional duties by medical and pharmaceutical workers, resulting in harm to the health of citizens or their death, the damage is compensated in accordance with the first part of Article 66 of these Fundamentals.
Compensation for damages does not relieve medical and pharmaceutical workers from bringing them to disciplinary, administrative or criminal liability in accordance with the legislation of the Russian Federation, the legislation of the constituent entities of the Russian Federation.
 Archive of pathology. – 1990. – No. 7. – S. 69-73.