Medical Errors

What is the difference between medical errors and medical negligence? In what cases should the medical staff be held accountable? Those cases were the focus of our discussion in a lecture at Harvard University while preparing my Master’s thesis in law and medical management.

At the beginning of the lecture, a variety of cases were presented to us, one of them was a nurse in an intensive care unit, embarked on a serious mistake, that occurred under harsh and exhausting work conditions, which eventually, led to the death of a patient. The nurse connected the food solution needle to the tube connected to the artery, rather than connecting it to the tube connected to the digestive system, directly causing the patients’ death. When the professor of the lecture asked the attending doctors: who believes that the nurse should be punished for her actions or be fired? More than three quarters of the attending doctors answered, that the nurse should be punished and fired. But after two hours from the lecture and the discussion, by revealing results of intensive studies made by the United States towards this subject, the lecturing professor asked the same question, only this time, the attending doctors unanimously revealed, that it was not necessary to fire or punish the nurse for her actions and that it was substantially necessary to investigate the system, or medical regulations of the hospital, which allowed or helped the occurrence of the error made by the nurse. This logic may seem strange to most people, including doctors. However, this was not a personal opinion made by the Harvard professor, but rather a result of intensive studies conducted in the United States, costing millions of dollars on continuous studies to that matter.

The purpose of those studies is to find out why those errors happened, and how we can avoid them in the future. In this article, I will shed the light on some of those results.

We began addressing our subject with a fact; the United States of America is most cautious when it comes to medical errors. And due to the easy process of legal trials against hospitals there, paying substantial compensations to patients as a result of medical errors with potentially hundreds of millions of dollars in some cases. However, there are more than 180’000 deaths every year as a result of medical errors, and those cases occur sporadically in more than 5000 medical centers across the country, we can also expect that this number multiplies within most countries of the world who do not enjoy the progress of medical science, educational and administration aspects as the U.S does. But the matter of fact is, statistics are not available, and the causes of death are unknown for the vast majority of the studies which documented this information.

Studies have shown that the main cause of medical errors is the wrong belief contradicting with the principals of human nature; this principal is that humans do not make mistakes.

Based on this principle, the medical organization in most hospitals depends on the accuracy of the medical staff and their ability to avoid any errors rather than to assume that medical errors would inevitably occur and that the medical organization or its regulation system should work towards prevention methods. Thus, studies suggest that errors occur in medical regulation systems of the hospital, rather than its medical staff, considering that humans, by nature, are bound to make mistakes or overlook them.

These studies has helped in redesigning many of the medical systems in the United States, and as an example, the error committed by the nurse, mentioned earlier, would not have happened if the food solution needle that was supposed to be connected to the digestive system tube, was made to only match the designated tube (Just like a person that cannot fill diesel fuel to a car that runs on gasoline because of the different design slots for each fuel type) and so, changing all the tubes and designing connections that fit to a specific kind of pipes could have avoided the nurse from making that error, even if she wanted to do so (this is what’s called proofing lirror).

Another example is relaying on computes to detect the presence of contradictions in dispensing medication to the patient, such as sensitivities and allergic reactions to certain medications, or incompatibilities with other medical drugs taken by the patient.

The American society of warnings has stated regulations, protocols and laws addressed to all anesthesiologists around the United States, which resulted in reducing deaths caused by anesthesia from one against each 20’000 to one against 200’000, and there are plenty of examples we cannot address at the moment. The bottom line is, medical concepts that overlooks medical errors by addressing them with punishing medical staff without considering the root of the problem and the reasons to why they occur will not result in desired outcomes towards avoiding similar mistakes in the future, but fields studies proved that it led to substantial fear and dread the recording, writing or recognizing errors, and thus, the continuity of errors in the system resulting them to increase with time, instead of establishing a punishment system that should be only in the cases of willful intent or negligence, or a clear violation of laws and regulations or other medical reasons that can only be judged by experts and adepts in that field. With such awareness carried out, hospital planning and regulations is built with responsibly to preserve trust on all aspects of its operations.

In that, we can say that the right way for medical organizations is to assume that errors are inevitable and bound to happen even by the best of doctors, because they are human. Medical regulations and systems should prevent mistakes from happening and address them in their early stages in case they occurred, that is why studies indicate that any medical mistake is often a result of an error in the medical system practiced in the hospital, and this in itself does not relieve physicians from the burden of responsibility towards the lives they were entrusted with, and punishment is not spared in cases of deliberate negligence or violation of  clear regulations and laws or other reasons that are judged by experts and adepts in this field, but the goal is to focus on the medical regulations that led to the occurrence of the mistake, in order to learn from those mistakes and avoid them in the future, with that correct understanding of medical errors, resulting the redesigning of many of the medical systems and regulations in America, that can be summed up in the misconception of medical errors, which does not exceed an attempt to punish medical staff without studying the roots and origins of the problem and the reasons for their occurrence does not result, in return, the desire to avoid similar errors in the future, but studies have shown that the concentration of efforts to punish medical staff and workers in the medical system creates fear and dread of mistakes and punishment, leading to hide mistakes and lack of recognition and responsibility, rather to attempt to investigate and treat the causes of those mistakes and why they occurred, and thus the continuity of errors in the system that are worsened with time, and where society as a whole loses the opportunity to benefit from its mistakes.

And in a new study done by researchers to study the reasons why patients file lawsuits against doctors, and studying the difference between those patience and the ones who didn’t file a lawsuit, and study the differences between the patients’ and doctors’ personalities and the differences between types of mistakes.

The study have shown that there is an inverse relationship between the probability of filing a lawsuit against doctors and how close the kind of humane relationship is between doctors and their patients, and it was found that the most important factor in deciding the probability of filing a lawsuit and the way doctors react towards patients after injuries and medical errors have directly affected them.

It was also found that, the first automated defense from hospitals and their doctors usually results in driving patients to file lawsuits against doctors and their hospitals, which could have been avoided if the doctors and their hospitals reactions would change.

Another study has also answered the question: What do patients want from filing lawsuits against their doctors, where cases of fathers whose children were born with neural damage, due to mistakes being made during birth, and studying the difference between those who file lawsuits against doctors and those who didn’t, and the fathers reasons were:

–          24% said: (The doctor was not honest with them, and that he was laying).

–          24% said: (They need financial support to secure their injured child).

–          20% said: (They acted out of a natural reaction when they have learned about their child’s destiny and future)

–          20% said: (They didn’t find anyone who could tell them the truth about what happened, and that they want to know the truth).

–          19% said: (They acted out of anger from what happened and had the desire to revenge from the doctor, due to his mistake and him insisting that he didn’t do any mistakes) or (They want to make sure that the mistake won’t happen again).

Most reasons for filing lawsuits were not for financial reasons, but a way to accomplish one of the following things:

1-      Open the door for discussion and study the reasons of those mistakes.

2-      Explain and understand what happened in all sincerity and honesty and for doctors and hospitals to apologies for what has happened.

3-      A true desire from hospitals and doctors to fix the reasons why those mistakes have happened, and to take the positive and right measures towards that way.

The American State of Massachusetts was one of the first states that have turned these points and concepts in to a working program, and so they initiated what was called ‘The Optional or voluntarily program for medical mediation and Reconciliation’, which was founded by the American Board in the state in collaboration with the bargaining program in the fields of health care and conflict resolution in Harvard University.

This program succeeded in resolving a lot of problems, and avoided many lawsuits and resolutions, and satisfied all parties in most cases using wisdom and applying justice, and we have found some conflicts worth mentioning to show how we can benefit from for both patients and doctors alike.

One of those cases happened in 1993, where an operation has been made to one of the patients in the ureter, but the patient’s pain continued after the operation, and although he followed up with his doctor and has complained about the pain, the doctor ignored the symptoms and the complains of the patient which forced him to go to another sergeant, and after he checked him he found that the previous surgery was unsuccessful, and so the second sergeant operated a corrective surgery to solve the problem. The patient however, suffered psychological, physical and financial damages, and during this ordeal, the patient tried calling the previous hospital to inform them about what happened, but he never found anyone to listen to him or even showed a true gesture to find out the truth about what has happened, which forced the patient to file a lawsuit against the doctor to the States American Board on the grounds that the doctor failed to explain to the patient that this kind of surgery has a high percentage of failure which comes to 10%.

And so the authorities of the state appointed one of the senior specialists in dispute resolution and arbitration, who was a board member to one of the big university hospitals assigning the date of meeting and convincing both parties to attend the meeting, and so, both the doctor and patient came with fuming anger, beginning with the patient attacking the doctor and accusing him of failing to explain the operations ricks before conducting it, with a high risk of failure that reaches to 10%. And here the doctor stopped intercepted the patient as he was astonished by the percentage mentioned by the patient and corrected him by saying that, it does not exceed 1% not 10%. The doctor then explained that, it was impossible for him to conduct the operation that had a percentage of failure of 10% without explaining it to the patient.

The doctor continued his talk apologizing for what happened and the suffering that was brought upon the patient, and all the pain he suffered from, and he explained to the patient that the real reason why he never answered his called was because of the hospital lawyers’ suggestion to him not to answer the patient’s calls.

The patient sensed sincerity in what was said by the doctor, although that the time assigned to this meeting was suppose to be 4 hours, but exactly 45 minutes after, the doctor and patient were shaking hands and the conflict was resolved.

Another example happened in December 1994, when a woman filed a complaint the American Board, according to the complaint; a urologist treating her old mother misdiagnosed her mother’s condition who was suffering from a urinary tract infection, the urologist assumed that the blood in the urine sample is a result of infections, and so prescribed and antibiotic for her over the phone without asking her to come to his clinic for a checkup, but the blood continued to show in urine, and she was submitted in the hospital, and discovered that she had bladder cancer in an advanced stage to which treatment does not work anymore, she died shortly after.

The State Board conducted a review on the case and on the doctors’ history, but due to the excellent medical record of the doctor throughout his years of practice, and so they could not establish that the matter needs punishment and referred the case and the complaint to the medical meditation and negotiation program mentioned earlier.

A negotiator has been assigned to the case, and the woman has clarified that she has no intentions of filing a lawsuit to the purpose or goal of any financial gain, and she does not expect one, and won’t accept it either, because there is no money that could compensate her from the loss of her mother, but she wants to make sure that this mistake and this tragedy would not be repeated to another patient.

During the negotiation session, the woman expressed to the doctor how sad she feels towards what have happened and her feelings towards his reactions and the mistake he has done, the doctor was listening with patience, and after she finished, the doctor expressed how sorry he was to what has happened to her mother which he was treating for so long, and had very close relations with her, and then he apologized for the mistake and agreed to the proposition made by the woman to join a medical education course about bladder cancer, and has also agreed to donate a thousand dollars to the American Cancer group as a nominal amount.

This case and others like it, confirm the facts we mentioned in the previous episode, that is, most filed lawsuits against doctors and hospitals when mistakes happen are not for financial reasons.

The question that we would like to answer now is: where does our doctors’ and medical clinics stand in our countries against patient complains and medical errors?

When I tried to insert those terms and concepts to our Arabic world and try and search and understand the current health situation, I found that there are major gaps between understanding the problem, analyzing its reasons between the therapist and the patient, and here are some research and polls results:

–          Most doctors and hospitals have no desire to listen to the patients complain.

–          There is no obvious, clear and published system in most hospitals to make it easy on the patient to express his opinion or file a complaint to the hospitals management to look into and check its aspects.

–          Most hospital reactions is defensive when patients complain, and usually putting the blame on the patient, as well as having no true desire to study the patients complain and correct the followed system if necessary.

–          A lot of doctors live in mentions and assume the ignorance of patients where then, they fall short to provide an adequate explanation to the patient or even to try and simplify medical terms for the patient, as an excuse for the limited knowledge of patients on medical matters.

–          A lot of the hospitals are purely profit oriented.

–          Medical treatment in western countries is more humane that the treatment in the Arabic world.

–          There is not information about doctors and hospitals that helps patients choose doctors over others or a hospital over another, and usually choosing one is based on unscientifically or correct information that is also not documented.

–           A medical manual does not exist in any hospital, that would include a lot of full reports on each doctor, their degrees, past experience and other information that can help patients to make decisions (like the number of operations done by a certain doctor, their types and how successful were they…etc).

–          A lot of the hospitals spends money on buying modern medical equipments, but fall short in bringing good doctors due to their high paid salaries.

–          There is public skepticism towards medical systems, and skeptic patients see more faulty things, their point of view are affected, and so are their conclusions.

–          The lack of knowledge on medical matters by patients subjects them to misunderstand between medical terms caused by the negligence and expected complications in a lot of the operations, and how that they are expected to happen in those percentages such as exactly what happens in the best hospitals of the world under the hands of the best of doctors.

–          There are still major complexities in Arab patients’ egos that mainly ends up controlling their reactions, and this is caused by the lack of many based structures suffered by huge categories of the community, and thus we find a patient convinced by everything said or mentioned by a western doctor, but suspects everything an Arab would say even if they were doctors more knowledgeable and experienced that a western doctor on most cases.

–          The skepticism dominating the medical system of hospitals drives patients to accuse hospitals with extortion and exploitation, in the meantime the same patients if they go and get treatment from western hospitals, they pay 10 times the treatment costs, without minding or denying what they have paid, even if it was from their own pockets.

–          Patients demand the enhancement of medical treatment, but at the same time, they are not willing to pay the price for that, and what an Arab citizen pay for treatment in general is much more less than what citizens pay in advanced countries.

I would like to open the door for discussion through my articles, and have already started receiving some responses that helped me to understand the psychological dimensions of the problem and the reasons why a huge gap is created between patients, doctors and treating hospitals.

And through our constant communications with people who are involved with medical resolutions and negotiations program in the fields of medical care in Harvard University that we spoke of earlier, and considering the importance of such subject, I have promised the ones who sent me to make this subject one of the main goals to invest my time and education to study it, and try to advance ‘even if for one step’ in the right direction, bringing back trust in the health system in Arab countries.