Download medical error and medical culture，An ethical dilemma

What can be trust?
The combined survey of medical
accidents and medical errors
Li Benfu, Cong Yali, Sun Fuchuan, Chen
Xiaoyang, Chen Pei, Zhu Kangmei, Fan
Mingsheng & Zhou Hongzhu
Outline
• The current situation of medical accidents
in China
• The survey of medical errors in 2008
• What can medical professionalism do for
patient safety?
Medical accidents
medical errors
• Medical accidents are 医
疗事故是指在诊疗护理过
成中，因医务人员诊疗护
理过失，直接造成人员死
亡、残废、组织器官损伤
导致功能障碍的。
• Be classified into 4
grades
• Medical errors is
dereliction of duty and
technological negligence
in the process of 医疗差
错是指在诊疗护理过成中，
医务人员虽有失职行为或
技术过失，但未给病员造
成死亡、残废、组织器官
损伤导致功能障碍的不良
后果。
• Subjective and objective
reasons
• Errors, disobey rules,
cause harm
The reasons of medical accidents——26
cases of a hospital in 2003
Item
cases
percentage（%）
misdiagnosis、missed diagnosis &
delayed treatment
6
23.1
Operative indication choice, operation
method and mishandling the observation
after operation
16
61.5
Improper use of drugs and adverse
reaction
2
7.7
Carelessness, disobey the concerned
rules
2
7.7
The current states of medical
accidents
• 47.8% happens on holiday and in the evening
• Most statistics shows that accidents happen often in
the orthopedics, obstetrics and gynecology .
• Mainly elders and youth
• Some statistics shows that there less accidents in the
first level hospital than the second level, less in the
second than the third level. But some survey shows
the contrary results.
The history of medical accidents in
China
• Period of exploration——1949-1956. over
punishment, limited compensation for patients.
administrative mediation.
• Period of improvement——1956-1965. Treat the
medical errors more reasonably, but the radical
phenomena does exist.
• Period of anarchy——1966-1976. Culture
Revolution.
• Period of legalization——1978 to now。1987,
Measures ; 2002, Statues
The reality that patients face
• Medical accidents are very few; most are medical
errors
• “The experience of foreign courtiers to deal with
medical errors”，Management Magazine of Chinese
PLA Hospital. No.6, 2002：In U.S.A medical errors
rank 8th in the death reasons.
• In China, major factors for medical error are: skills,
incompetence, faultiness of the basic regulations
and imperfect supervision
The attitude of physicians to
medical errors—
the combined survey in Harbin,
Beijing, Jinan, and Shanghai
Sharing results
sample （396）
• beijing：140（眼科、产科等）
• shanghai：58（内科和外伤）
• jinan：100（妇儿、外科、内总、五官、，
门诊——各20）
• harbin：98
5.According to your observation, the
rate of medical error around you?
• A. 0～5% B.5～10% C.10～15%
其他：如< % 或 > %
90%以上选择A.
D.
One special point, beijing baby delivery：
38.8% select B，or C。
Harbin pediatrics: 37.5%
6.After medical error happened, you
found how your colleagues to deal with
A.don’t let leader knows
B don’t let colleague knows
C.don’t tell patient first, but observe and check
carefully
D.Tell department, but keep secret to outside
E.others：
• 选择C：33.3% 【132（396）】
• 选择D： 36.4% 【144（396）】
7.Do you once make medical error?
•
•
•
•
•
•
•
•
if yes, who you once tell：
A.colleague；
B leader.
C.lower colleague；
D. family；
E.patient；
F.others
选择A和B居多，其中B要多于A。 B > A
8.IF happened by yourself, how much percent you
should take responsibility?
%，
other factors, please fill at least three items
• Most: 10-20%。One eldest，73 yrs, he
answered 50-60%。
• Other factors：patient not cooperation,
work pressure, too tired, complicated
disease, not developed system of rule and
regulation, and the work exchange time.
eg. Some patients not polite, and rude, so
physicians very worried, and usually esay
to make something wrong
9.If don’t want to tell colleage and
leader, what is the main reasons
• A. afraid leader think uncompetent；
• B. afraid colleague think lower level; C.
afraid affect the promote of position D.
afraid punishment on bonus E．others
明显地，选择A C和D
• 疑问：现实中的医生差错发生，与相继的
医院、科室对其的经济处罚，到底是否进
行了客观的区分和考虑
10. If don’t want to tell patient, the
reasons：
•
•
•
•
A.sue, court；
B.tell the media
C.not necessary to tell pt
D.others：
reason：pt will not understand physicians,
don’t trust physician, quarrel, hit doctor,
sue doctors.（nothing is impossible）
Special point
• Hard to answer, some not serious, or one take
several questionnaires
• But still there exist many true response.
Something like communicate with them
• Different depts, and hospitals, sometimes can
show the obvious differences. If sample large
enough, can find some factors related to hospital
education environment, and different hospital
rules and its relationship with medical error
医疗差错对待，医师职业精神的核
心问题之一——谁的利益至上？
• 新型的利益冲突——患者生命安全利益 Vs 医生的经济
利益和名誉等其他利益
• 目前不利的表现：
– 观念上的扭曲——都清楚这是客观存在的事实，但又认为不能
“承认”；
– 行政管理措施：报告则意味着处罚—经济和名誉（如美国的高额
赔付的风险赔偿机制也在一定程度上制约着医疗事故的自愿报告；
我国的“面子”方面、“被歧视”等心理；
– 有空子可钻：不报告有可能对自己没有负面的影响。
• 客观上，不信任的医患关系，更加阻碍了医疗差错的报告，
也因此丧失了医生从差错中学习的机会。
• 我国，仍然缺乏认错、反省、互相理解等机制和传统。患
者对差错也缺乏客观的认识。
Share experience
• Shouldn’t inform the patients. Otherwise it
will lead such results: misunderstanding by
patients, mistrust by patients, quarreling
with doctors, prosecution, battery, etc.
（nothing is impossible）
• Don’t report to the hospital administrators.
Otherwise you will be punished.
Whose interests are first?
• New model of interests conflicts: patients’ safety vs.
doctors’ interests
• Some adverse phenomena：
– Distortion of ideas——it is objective, but some do not accept it.
– Administrative measures: report means punishment
– Exploit an advantage. There are some bad effects with no report.
• Objectively, the mistrust between doctors and patients
hinders the report of medical errors. So doctors lose the
chance to learn from the errors.
• There is no tradition of misknow, reflection and mutual
understanding. Patients have no objective knowledge of
medical errors.
What can be trust for patient safety？
• Foreseeable：dealing with accidents,
compensation, report of medical errors,
building the safety system, the team work,
etc.
• Unforeseeable ：the attitude to medical
errors, the psychological stats after errors,
etc.
The construction of Error
report system——visible
• 任仲杰，the report
system of medical error
and medical accident in
U.S ，中华医院管理杂志，
2006年06期
• In U.S, there are more
and more evidences that
the report system of
medical error and medical
accident would promote
the medical quality and
security. It is adopted in
mostly hospitals.
the atmosphere of trust,
understanding ——invisible
• Peter Singer etc，The
ethical dilemma –medical
error and medical culture，
An ethical dilemma--Medical
errors and medical culture-<<英国医学杂志中文版 >>2002年03期
• Commentary:
Learning to love
mistakes
• Doctors are obliged
to be honest with
their patients
What can be done for medical
professionalism on medical error
• Take more objective education on medical error to
medical students
• Educated differently ---for physicians, for hospitals, for
patients, for doctor-patient understanding etc.
• Constitute for the long term doctor-patient relationship
with understanding and trust, so we can create medical
humanity idea
• Changing the culture of blame——whether a culture,
in which there is more trust and security between doctor
and patients, can be constructed? Changing the culture
of blaming doctors only (excluding the subjective factors
like responsibility ) ?