What is considered a doctor's subjective errors? Ways to prevent medical errors

Alexander Saversky, a member of the expert council under the Russian government, and president of the League for the Defense of Patients' Rights, recently visited the Pravda.Ru studio. He discussed with editor-in-chief Inna Novikova such a painful topic as medical errors. How do they arise and why do they mostly remain uncorrected?

IN: As I understand it, Alexander Vladimirovich, this is such a painful topic that God forbid you and I can get through it in an hour of conversation. Because 80 percent of medical errors go unpunished (according to your own statistics)... Are you dealing with those same mistakes and trying to figure it out and find those who are right and wrong?

AS: I think that, yes, it is. Moreover, 80 percent is such a very gentle statistic, because in reality, if we speak based on the statistics of the Federal Compulsory Medical Insurance Fund, then we have about 10 percent of assistance with, and this means 40 million hospitalizations in the inpatient department, respectively

4 million defects. About 3 thousand cases a year reach the court.

IN: What are defects in this case?

AS: This is a doctor’s deviation from the standard, order, law, that is, he violates some rules, either his medical and scientific ones, or the law. And such assistance is 10 percent, from the assessment of insurance companies. Specialists conduct examinations of quality medical care; there are about 8 million such examinations per year. About 800 thousand defects are detected. Can you imagine? And it would seem that there should be a good order in such identification. Nothing of the kind, because insurers simply impose small fines on the general public policy. And patients are not even informed about this, these defects. Imagine revealing that there was a medical error and not informing the person about it!

IN: Tell me, if a person doesn’t know about it, how is this medical error detected?

AS: It doesn’t come to light at all. People often seem to understand that something was wrong, but they don’t have this report from the insurance company, so they, accordingly, either don’t know, or they go around, poke around, try to explain and prove in some of their own ways , contact us sometimes.

IN: So, what are they trying to explain? “Something was wrong, I didn’t like something, but I don’t know what.”

AS: No. We are talking about health, about harm to health. That is, a person, as a result of “I don’t know how,” could lose an arm, leg, or organ there. That is, these are serious things.

IN: Can we understand whether the doctors are to blame or whether the circumstances have somehow turned out that way?

AS: If we talk again about the statistics of insurance companies, then again, insurance company experts do not see the patient himself, they evaluate the medical history, how they were treated. And even

According to these documents, 10 percent are found. And if you consider that, for example, academicians themselves say that in Russia we have 30 percent of incorrect diagnoses, and the insurance company expert cannot understand from the documents whether the diagnosis was correctly established, then the figure has already swum from 10 percent to 30. And pathologists they say that there is 20-25 percent of discrepancies between lifetime and post-mortem diagnoses. That is, every fourth death is from the wrong disease, from the wrong cause that was established during life, that is, they were treated for the wrong thing. Therefore, in reality, the statistics are, of course, absolutely terrible; they are two or three times higher than the average European and American ones.

IN: Alexander Vladimirovich, what do you want to change in general in such a situation?

AS: Are you suggesting not to start?

IN: No, no. Well, you started 12 years ago and all the time you are faced with some glaring facts.

AS: I have a very serious victory. Over the past 6 years, I have never been asked: “Who are you protecting, who is the patient?” Because, you won’t believe it, but in 2000 (this is how people’s mentality is changing after all, it is changing, thanks in particular to us), but in 2000 every second person literally asked “excuse me, please, but who are you protecting, who is the patient?”, even journalists did it. Here. The one who is being treated is the patient.

IN: Who has a voucher to see a doctor, yes.

AS: Yes. "Let's talk about terms." Unfortunately, the system is insane, one of the most inert. With all the shortcomings of the socialist system, these non-market relations have also been added.

IN: Crisis and post-crisis problems.

AS: Absolutely right. Healthcare today is truly monstrous from every point of view. He really needs to be treated, loved for who he is, given money, filled with care from the state, otherwise we will all suffer from this and be scared.

IN: Wait, Alexander Vladimirovich, you yourself said that you used to think that healthcare has no money, it needs to be helped, given money, but now you have found out that there is a lot of money, but we don’t know how to manage it and organize everything.

AS: Yes, the fact is that they are coming and going, there is money, and I will repeat this and repeat it. Moreover, there is still a lot of unaccounted for, because when the state starts saying “we have such a budget,” and I ask, guys, have you taken into account the money of neighboring ministries and departments (we have 20 ministries and departments that have their own healthcare system). Immediately you realize that there are still oh-oh-oh-oh-oh-oh-oh-so-so places in your pockets where you can climb. The money, in my opinion, is distributed incorrectly, because for example, a doctor who treats in a hut on chicken legs, but receives a good salary for real and understands that he is cared for, will treat a patient much better than a doctor in a glass building and concrete with millions of equipment. But with a salary of 15 thousand, and working 2-3 shifts, 2-3 jobs, the first doctor, simply with his care, will help the patient much more than this doctor, to whom it is simply dangerous to go. He is a tired man, abandoned, who does not have time to learn modern technologies.

IN: Are you talking about someone who sits in a hut, receives a good salary, or about someone who sits in a big building?

AS: No, of course, the one who sits in a large building is more dangerous than the one who sits in a hut, because the second one does not have time to study or take care of himself, he has no time for the patient. Well, this is such a born surrogate of our healthcare system, this is not a doctor.

IN: Do you think it’s all about salary?

AS: I think the whole point is a lack of concern on the part of the state, and wages are one of the most serious indicators here.

IN: How can you determine where the salary is high and where it is small?

AS: It’s simply determined, the salary is 5 thousand rubles. Can you imagine? This is the salary of our doctors in the regions, she posts receipts on the Internet, I have many friends there who are doctors, look, 5 thousand per month.

IN: Kvitochek. And they live on these 5 thousand rubles.

AS: Well, what do they live on, that’s another question, because in reality 5 thousand... A doctor should sit in his place, there from 8 o’clock in the morning until three and receive a good salary, at least 2 thousand dollars.

IN: Who decided that it should be 2 thousand dollars?

AS: Doctors call this figure, and I internally agree with it now. Let's say, in 2000, when this figure was mentioned, I considered it arrogance; now it is a normal figure.

IN: What is the average salary of doctors in the regions and in Moscow?

AS: In Russia they say about 17 thousand, in Moscow the situation is completely different, 60.

IN: That is, the same 2 thousand dollars.

AS: This is already money, yes. For Moscow, let’s say, 60 thousand is probably the minimum level that a doctor should receive.

IN: Should he receive this from budgetary organizations?

AS: Not that it’s against... It’s like the costs, the shortcomings of our free public health care system. I am well aware that if the state system works well, not normally, but well, then 90 percent of private medicine in Russia, which is now developing, will die.

IN: Why is there a private one in Europe?

AS: Because healthcare developed differently there. See, the fact is that creating a government-run healthcare system is insanely expensive. It’s just, you know, because it’s just very expensive to build a huge number of institutions on the required scale. We did this in the Soviet Union and now we are trying to give these institutions back to private owners, that is, take a step back. This is complete nonsense.

The state announced that it would grant concessions to public institutions to private organizations. Here. Accordingly, in place of the state organization there will be a surrogate, a private public partnership, which will make money on everything that moves.

IN: Before that, private people didn’t make money on everything that moved?

AS: It’s not that they made money from themselves.

IN: Didn’t you make diagnoses that don’t exist?

AS: The fact is that now in place of state clinics there will appear such an incomprehensible creation.

IN: Will there appear instead of district clinics?

AS: For example, on the site of the 63rd city hospital in Moscow, it will already appear. And a number of departmental medical organizations have already become private.

IN: Which departmental medical organizations?

AS: This concerns... Well, let's put it this way, the MedSi network largely exists in this way. Yes, ministries.

IN: That is, ministries, but they actually began to get rid of social services a long time ago, because it is difficult for them, it is difficult to maintain clinics and dispensaries.

AS: You see, in such cases I always remember this very thing: “Ivan Vasilyevich is changing his profession,” “Why are you, you tsar’s face, squandering the people’s lands.” And who gave them the right to get rid of state property? These people earned money for themselves, using our taxes.

IN: What do you mean?

AS: What do you mean?

IN: What kind of people earned money for themselves?

AS: People, this is people's property.

IN: I know a number of enterprises that had a large social sphere, and industrial enterprises, large, manufacturing, serious. And they were told “deal with yours yourself

sanatoriums, health resorts

AS: I'm talking about the public health care system, I'm only interested in it. When the ministry gets rid of public health care institutions, it annoys me, because, strictly speaking, they were built with public money. Why are they suddenly getting rid of them? Medical care should continue to be provided there. Some high technology centers are starting to be built. That is, we fuse one thing, we build another. No amount of money will ever be enough, dear comrades.

IN: We are actually sawing the third one.

AS: Yes, yes. You see, this is actually crazy. Moreover, all this is done in such a closed, in-person manner, that is, “but we have decided.” What did you decide? Who gave you the right to decide this? Because we have Article 41 of the Constitution, the state guarantees assistance from state municipal institutions free of charge. Well, then, if you please, implement the Constitution. Why are you starting to organize some games there with private-public partnerships?

The state institution was leased, and another entity arose there, a public-private partnership, another one, not a state institution. The status is different, you know, this is very important. Because a state institution is an organizational and legal form, a status. If the status is changed, bam, the guys from the Constitution jumped, left and no longer owe anyone anything, no free help. Therefore, the requirement of the Constitution does not formally apply to him.

IN: That is, the Constitution of the Russian Federation will not apply to those companies, not only medical ones, in which the state participates partially.

AS: We are only talking about medicine. I'm talking about Article 41 of the Constitution, which says that medical care to citizens in state municipal institutions is provided free of charge.

IN: Okay, let's get back to the topic of protecting patients' rights and the mistakes and standards that doctors should adhere to. That is, do we have any strict standards for doctors on how they should conduct diagnostics, examination, treatment, and postoperative measures?

How strictly regulated is this?

AS: From 2004-4 to 2007, about 700 standards were adopted; according to the current law, they are mandatory, although the Ministry of Health is constantly fluctuating on this issue. Either they are optional, or they are for economic calculations. But I'm talking about the law. They are legally binding. In principle, we quite often use this in court as follows. We take the medical history, compare it with the standard, that is, there is already a diagnosis in the medical history, you take...

IN: Which may be 30 percent wrong.

AS: You know, in this sense it’s very interesting. Because it is almost impossible to know the whole story from beginning to end, especially when a person died. We don't know exactly how he died, unfortunately. And indeed, in this situation, the medical history serves as almost the only source of information, evidence and information. And the absurdity of the situation is that we often punish doctors not for what they did, but for what they wrote. Because to write a medical history correctly, for this you already need to be a very good doctor and not

drive yourself into a pitchfork, into scissors, because... For example, you often come across a situation where a person dies from anaphylactic shock, and the doctor begins to rage there. Guys, why are you freaking out? This is not your fault at all. Did you break anything? No. Why are you hiding then and writing some nonsense in your medical history? Just to hide the fact that there was some kind of anaphylactic shock. Was he? Was.

IN: That is, it’s easier to write that there was some kind of heart attack.

AS: Of course, we need to admit things, because in fact, when a doctor acts correctly, without violating anything, he is not guilty, no matter what happens to the patient. There is another problem, he... in anaphylaxis, people often die not even from the shock itself, but because there was no timely post-shock care.

And here, when he spends two hours trying to resuscitate him, having neither the skills nor the equipment for this, and the person dies, here, excuse me, is the failure to provide medical care, resulting in death.

IN: That’s why they’re trying to hide it.

AS: That’s not what they’re hiding. They begin to come up with some kind of bleeding, something completely crazy. Here. Because there is no simple knowledge that if you did everything correctly in this part and you didn’t have to take allergy tests, it’s just not possible to do it for all drugs, then it’s not your fault.

IN: Alexander Vladimirovich, when anaphylactic shock occurs somewhere in a dental clinic from an injection of the simplest, yes, painkiller, that’s one story. And when this happens in the operating room, as was the case with the patient at the clinic, and before the operation, she was asked “do you have it?”, “no.” Where? She doesn't know what she has.

AC: Well, of course yes.

IN: At the same time, accordingly, some tests, some tests should probably be carried out before operations.

AC: This is an incredibly difficult question. Firstly, indeed, the fact is that anaphylaxis is such a thing that it depends little on the amount of the substance administered. An allergic reaction occurs immediately and is systemic in nature. Secondly, the fact is that if you think about dentistry, then, strictly speaking, here we always have violations of the law and even even criminal violations, under Article 235. The fact is that dentists, of course, do not have the right to practice anesthesiology.

St. Petersburg Research Institute
Institute of Emergency Medicine named after prof. I.I.Dzhanelidze

CHARACTERISTIC MEDICAL ERRORS
IN THE TREATMENT OF SEVERE ACUTE PANCREATITIS

(manual for doctors)

Part 1. Typical errors and their classification.

St. Petersburg, 2005

INTRODUCTION

This manual for doctors is devoted to a problem that is written about little and reluctantly. However, the subject we are about to consider deserves the closest professional attention and careful analysis. We mean characteristic errors in the treatment and diagnosis of severe acute pancreatitis.

Before moving on to the materials of the proposed manual, we should, if possible, briefly give the student doctor a modern definition of medical error, which is an inevitable shadow of clinical practice.

An unsuccessful or harmful action of a doctor already in ancient times could lead to exclusion from the medical community (931 AD) and to the deprivation of a certificate for the right to heal (Az-Zahrawi, 1983; cited by Shaposhnikov A.V., 1998 ).
But even in our time, errors in medical practice still remain an objective factor leading to adverse consequences for both the patient and the doctor.
Medical errors are by no means uncommon.

According to the Russian press, 190 thousand patients die annually in US hospitals from medical errors. ["Science and Life. 2005 No. 5 p. 100.]. However, even in the United States they are reluctant to pay attention to this problem.

The more severe the disease and the less studied it is, the more often deviations from various algorithms, evidence-based recommendations, standards and instructions are made, which is always fraught with the possibility of making dangerous errors in diagnosis and treatment.
The literature on medical errors is rather scarce. Doctors rarely and reluctantly write about their own mistakes.

This manual is addressed primarily to heads of surgical departments, leading surgeons of hospitals that provide care to patients with severe acute pancreatitis, as well as to methodologists and students: clinical residents, graduate students and interns.

Let's return to the topic of medical errors, which we will supplement with several cases from the practice of treating pancreatic necrosis, rich in examples of numerous severe, sometimes incurable, complications.

The bibliography of the problem that interests us is very meager. There are practically no publications that discuss errors in the diagnosis and treatment of severe acute pancreatitis. The lack of publications discussing typical errors is to some extent compensated for by the texts posted in the Medline information resources. Searching for messages on the topic under discussion in the resources of these search engines is, in general, unproductive and is limited to rare descriptions of special cases of treatment and diagnostic errors.

Errors in the process of diagnosis and treatment are called differently in different sources: medical, medical, therapeutic and diagnostic.

Definitions of medical error

Here are several different definitions of medical and/or medical error.

“Medical error” is defined as an action or inaction of individuals or legal entities in the processes of organizing, providing and financing medical care to a patient, which contributed or could contribute to a violation of the implementation of medical technologies, an increase or failure to reduce the risk of progression of the patient’s disease, as well as the risk of new pathological process. “Medical error” also includes suboptimal use of health care resources (Komorowski Yu.T., 1976).

The definition of “medical error” is close in content to the term “medical error”, but is somewhat different from it.

“Medical error” is defined as a preventable, objectively incorrect action (or inaction) of a doctor that contributed or could contribute to a violation of the implementation of medical technologies, an increase or failure to reduce the risk of progression of a patient’s existing disease, the possibility of a new pathological process, as well as suboptimal use health care resources and ultimately lead to dissatisfaction among health care consumers.”

Most of the above definitions were taken from the official website of the territorial compulsory health insurance fund, on which the “Regulations on the procedure for conducting non-departmental control of the volume of medical care and examination of its quality in St. Petersburg” dated May 26, 2004 was published.
In modern, especially foreign, literature, the quality of medical care indicator is used as an integrating indicator.

“Medical care” is defined as a set of activities, including medical services, organizational, technical and sanitary and anti-epidemic measures, drug supply, etc.) aimed at meeting the needs of the population in maintaining and restoring health.”

Treatment and diagnostic errors are an objective factor that worsens treatment results. They are negative phenomena that contribute to an increase in the length of stay of patients in hospitals, a decrease in the quality of medical care, an increase in the incidence of complications and an increase in the financial costs of medical institutions.

In an effort to reduce treatment and diagnostic errors, orders, “protocols”, evidence-based recommendations, treatment and diagnostic algorithms and, finally, standards have been developed in Russia and abroad that are designed to reduce the frequency and danger of treatment and diagnostic errors made by prehospital and hospital doctors stages of the emergency medical service.

Based on instructional and methodological documents developed by organizations such as the British Society of Gastroenterology and the International Pancreatological Association, doctors from different countries carry out an “audit” of these documents, comparing the results of actual practice with the standards published in these instructional and methodological documents.

In the Northwestern Federal District of the Russian Federation, such a document is the document “Acute pancreatitis (Protocols for diagnostic treatment) ICD-10-K85” [For the first time, a document regulating the scope and appropriate scope of diagnostic and therapeutic measures for the first time in our country was issued in the form of Order No. 377 of the Main Directorate of Health Care of the Executive Committee of the Leningrad City Council on July 14, 1988. Changes in the composition of appropriate therapeutic and diagnostic measures at the turn of the 20th and 21st centuries are reflected in “Protocols for diagnosis and treatment. Acute pancreatitis." St. Petersburg, 2004], approved by the Association of Surgeons of the North-West of the Russian Federation on March 12, 2004.

This document allows you to evaluate the quality of diagnosis and treatment of acute pancreatitis, as well as qualify errors in order to eliminate them and increase consumer satisfaction with the quality of medical care.

At the end of the 20th and beginning of the 21st centuries. New theoretical concepts, new diagnostic and treatment methods have appeared, also associated with the risk of developing previously unknown dangers, errors and complications.

Krakovsky N.I. and Gritsman Yu.Ya. (1967) surgical errors include all actions of the surgeon that unwittingly caused or could cause harm to the patient.

Foreign authors define medical errors in various terms: “medical malpractice”, “la faut contre la science et technique medical”, “der arztliche Kunstfehler”, “l"errore medico”, “hazard”, “inadvertent diagnosis”, “iatrogeny” and the like.

Komorovsky Yu.T. (1976) proposed an original, carefully developed, but overly detailed classification of medical errors. This author distinguishes between types, stages, causes, consequences and categories of errors. The administrative aspect of doctor errors extends, according to Komarovsky, from “misconception” and “accident” to “misdemeanor” or “crime”.

This exhaustively complete and, as a result, overcomplicated classification covers all currently conceivable types, stages, causes, consequences and categories of medical errors.

Komorovsky Yu.T. (1976) distinguishes between diagnostic, treatment and organizational errors that can be made at various stages of emergency medical care (in the clinic, at home, in an ambulance, in the emergency medicine department, in the hospital admissions department, in the process of examination, diagnosis, establishment indications for a particular treatment method at all stages of inpatient treatment (surgical or conservative), both in the preoperative and postoperative periods.

As follows from this “category” of medical errors, they can have completely different consequences (both medical and administrative), both for the patient and for the doctor who made them.

The additional complexity of describing “characteristic medical errors” may be due to the characteristics of the pathology, the degree of its complexity and knowledge, etc.

Classification of medical errors (according to Komarovsky Yu.T., 1976)

1. Types of medical errors

1.1. Diagnostic: for diseases and complications; on the quality and formulation of diagnoses; by discrepancy between the initial and final diagnoses.

1.2. Therapeutic: general, tactical, technical.

1.3. Organizational: administrative, documentation, deontological.

2. Stages of medical errors

2.1. Pre-hospital: at home, in a clinic, at an emergency station.

2.2. Inpatient: preoperative, operational, postoperative.

2.3. Post-hospital: adaptation, convalescence, rehabilitation.

3. Causes of medical errors

3.1. Subjective: moral and physical shortcomings of the doctor; insufficient professional training; insufficient collection and analysis of information.

3.2. Objective: unfavorable characteristics of the patient and the disease; unfavorable external environment; imperfection of medical science and technology.

4. Consequences of medical errors

4.1. Non-severe: temporary disability; unnecessary hospitalization;

4.2. Unnecessary treatment, disability, death.

1.1. Types of diagnostic errors

1.1.1. For diseases and complications: by main, competing and combined diseases; on concomitant and background diseases; on complications of diseases and treatment.

1.1.2. According to the quality and formulation of diagnoses: unidentified(lack of diagnosis when the disease is present); false(presence of diagnosis in the absence of disease); incorrect (mismatched in the presence of another disease); erroneous(there is no named disease); viewed(the disease being sought is not named); untimely (late, belated); incomplete(the necessary components of the diagnosis are not named); inaccurate(poor wording and editing); ill-conceived(unsuccessful interpretation and placement of components of the diagnosis.

1.1.3. According to the discrepancy between the initial and final diagnoses at the stages of observation: community and clinical diagnoses; pre- and postoperative, clinical and pathological diagnoses.

1.2. Types of medication errors

1.2.1. General: unindicated, incorrect, insufficient, excessive, delayed treatment; incorrect and untimely correction of metabolism (water-salt balance, acid-base balance, carbohydrate, protein and vitamin metabolism); incorrect and untimely selection and dosage of medications, physiotherapeutic procedures and radiation therapy; prescription of incompatible combinations and erroneous use of drugs, improper dietary nutrition.

1.2.2. Tactical: from delayed and inadequate first aid and resuscitation, improper transportation, unreasonable and untimely indications for surgery; insufficient preoperative preparation, incorrect choice of anesthesia and surgical access, inadequate audit of organs; incorrect assessment of the body's reserve capabilities, the volume and method of the operation, the sequence of its main stages, insufficient drainage of the wound, etc.

1.2.3. Technical: deficiencies in asepsis and antisepsis (for example, poor preparation of the surgical field, additional infection), unsatisfactory decompression of stagnant contents of hollow organs, formation of cracks, closed and semi-closed spaces, poor hemostasis, failure of ligatures and sutures, accidental leaving of foreign bodies in the wound, unsuccessful placement, compression and poor fixation of tampons and drainages, etc.

1.3. Types of organizational errors

1.3.1. Administrative errors are just as diverse, from irrational hospital planning to insufficient control of the quality and efficiency of medical work.

1.3.2. Documentation: from incorrect execution of operation protocols, documentation, certificates, extracts from medical records, sick leave certificates; shortcomings and gaps in the preparation of outpatient cards, medical histories, and operating logs; incomplete registration logs, etc.

1.3.3. Deontological caused by improper relationships with patients; poor contact with their relatives, etc..

2. Subjective causes of medical errors

Here we can mention an extensive list of the doctor’s shortcomings, from moral and physical to lack of professional competence.

3. Typical errors in the process of diagnosis and treatment of severe acute pancreatitis

The subject of this manual is an analysis of the most typical errors made in the process of diagnosis and treatment of patients with severe acute pancreatitis.

3.1. Objective reasons for diagnostic errors

3.1.1. Unfavorable characteristics of the patient and the disease: old age, decreased or loss of consciousness, severe agitation, extremely severe or terminal conditions, mental disability; simulation or dissimulation on the part of the patient and underestimation (anosognosia) or exaggeration (aggravation) of the severity of the disease by the patient. , Diagnostic errors are facilitated by states of drug or alcohol intoxication, senile dementia, mental illness, severe obesity, altered reactivity of the body, drug idiosyncrasy and allergies; the rarity of the disease, the asymptomatic and atypical nature of its course, the early and late stages of the pathological process, as well as the accompanying symptoms of background and concomitant diseases, as well as various complications.

3.1.2. Unfavorable environment: poor lighting, heating, ventilation, lack of necessary equipment, instruments, medicines, reagents, dressings; unsatisfactory laboratory performance, lack of consultants, communications and transport; absence, inaccuracy and incorrectness of information from medical personnel and relatives of the patient; insufficient and incorrect documentation data, short-term contact with the patient.

3.1.3. Imperfection of medical science and technology: unclear etiology and pathogenesis of the disease; lack of reliable methods for early diagnosis; insufficient effectiveness of available treatment methods; limited capabilities of diagnostic and therapeutic equipment.

All established diagnoses must be accompanied by the date of their discovery. Analyzes should be monitored over time to identify trends in the course of the pathological process.

Analysis of treatment errors includes an assessment of the individual validity of indications for certain therapeutic or instrumental diagnostic measures, as well as their timeliness. In order to prevent errors in surgical treatment, it is of great importance proper preparation of the preoperative report(epicrisis), including the following information:

1. Reasoned diagnosis;

2. Features of the patient and the disease;

3. Operational access and planned operation;

4. Methods and means of pain relief;

5. Informed consent of the patient or his authorized representatives to perform an operation or other instrumental intervention, recorded in the medical history and endorsed by the signatures of the patient, the attending physician, the head of the surgical department or the head of the clinic, indicating the date and hour.

6. Discussion of the most severe patients at morning conferences, regular rounds of the chief surgeon and head of the department. Clinical reviews of patients scheduled for surgery, etc.

7. If indications for emergency surgery are identified in a patient with acute surgical disease of the abdominal organs, proper preoperative preparation must be carried out, the composition, volume and duration of which depend on the specific circumstances. In diseases such as severe acute pancreatitis or peritonitis, diagnostic measures must be simultaneously accompanied by preoperative preparation, which is especially important when treating patients with severe acute pancreatitis.

8. Ethical, deontological, epistemological and psychological aspects of medical errors must certainly be taken into account.

9. Some errors are due to imperfect scientific knowledge, which is especially important in such complex multicomponent pathological processes, such as, for example, early severe acute pancreatitis, accompanied by a variety of systemic and local changes in the body. The first and decisive criterion for the correctness or error of a doctor’s professional actions is his compliance or violation of the norms of modern medical science, firmly established, generally accepted scientific facts, rules and recommendations emanating from specialized institutions that have accumulated rich experience in emergency surgical pathology.

Currently, surgeons have access to a significantly larger amount of information, which is important for the successful treatment of acute surgical diseases in general and acute pancreatitis in particular.

Considering the importance of thorough, accurate and, at the same time, gentle intraoperative diagnosis in severe acute pancreatitis, this issue should be given special attention.

3.1.4. Possible errors in intraoperative diagnosis of pathological changes in patients with severe acute pancreatitis

Intraoperative examination during laparotomy or laparoscopy for various forms of “acute abdomen” is the most important stage in their recognition, despite the use of ultrasound, computed tomography and endoscopic diagnostic methods. Only it can give an accurate idea of the pathological process in all the diversity of its manifestations. With the most complex pathology, which, due to the variety of variants and prevalence of the lesion, includes acute destructive pancreatitis, the importance of intraoperative diagnosis increases immeasurably. In no other acute surgical disease are the adequacy of surgical management and outcome so strongly dependent on the quality of intraoperative revision. A complete diagnosis during surgery requires the surgeon to both carefully identify the morphological signs of the disease in all anatomical formations and adequately interpret the data. These aspects of intraoperative diagnosis in acute pancreatitis are associated with additional difficulties due to:

anatomical features of the location of pancreas in the retroperitoneal space;
multicomponent pathological process;
variety of types of tissue necrosis;
variability of morphological signs of acute pancreatitis;
depending on the scope of revision on the nature of changes in the pancreas.

3.2. Intraoperative diagnosis of the form, prevalence and complications of severe acute pancreatitis

3.2.1. Objectives and sequence of the survey

The task of intraoperative diagnosis in acute pancreatitis is to clarify the morphological and clinical forms and extent of the disease in order to select adequate techniques and the extent of the operation. In the case of acute pancreatitis, making such decisions is especially important and difficult. Unlike other forms of “acute abdomen”, in uncomplicated cases characterized by damage to the corresponding organ, with destructive pancreatitis, pronounced pathological changes are also observed in the retroperitoneal tissue, omental bursa, peritoneum, greater and lesser omentum and other anatomical formations. Such components of local pathological reactions as parapancreatitis, paracolitis and paranephritis, peritonitis and omentobursitis, omentitis, ligamentitis in combination with concomitant acute pathology of the biliary tract, as a rule, are the main potential targets for surgical interventions. If in acute appendicitis the diagnosis clearly determines the nature of the operation, then in acute pancreatitis, in order to resolve the issue of the surgical technique and its volume, additional information is needed on the severity of all components of the pathological process. Therefore, intraoperative examination of the abdominal cavity in acute pancreatitis should include examination of all of the above formations, and the identified components of local pathological reactions must be detailed and accurately reflected in the postoperative diagnosis.

The starting point of intraoperative revision is the preoperative diagnosis, which must be confirmed or rejected by identifying or excluding other pathology. If the preoperative diagnosis is not confirmed or the detected local changes do not correspond to the clinical and laboratory picture of the disease, a systematic examination of the abdominal cavity is required (for example, clockwise) with an accompanying examination of the subphrenic spaces, retroperitoneal tissue, intestinal loops and pelvis.

However, if a phlegmonous or gangrenous inflammatory process, perforation of a hollow organ, fibrinous or purulent peritonitis is detected, further revision is stopped in order to avoid dissemination of the infection in the abdominal cavity. For example, if gangrenous cholecystitis and serous-fibrinous exudate with high amylase activity in the subhepatic space are detected, “acute cholecystopancreatitis” should be diagnosed and further inspection of the abdominal cavity and omental bursa should be refrained.

In fact, the retroperitoneal location of the pancreas makes it very difficult to examine during surgery. Its capabilities are also limited by the extreme sensitivity of the pancreas to surgical trauma and circulatory disorders. To examine the pancreatic tissue itself, it is necessary to carry out additional techniques to access and expose the parenchyma, which should not be unnecessarily traumatic and increase the duration and risk of the operation. The volume of necessary and justified intraoperative revision of the pancreas and its surrounding structures depends on the degree of their involvement in the pathological process, its form and stage.

Wide surgical exposure of the pancreas in some cases is a prerequisite in the fight for the life of a patient with destructive pancreatitis, and sometimes has a detrimental effect on the further course of the disease, creating conditions for exogenous infection of the pathological focus. In the absence of data indicating a high likelihood of developing widespread pancreatic and retroperitoneal destruction, mobilization of the pancreas is not justified. Moreover, it cannot be justified solely by the need to examine this organ.

Considering the close anatomical and physiological connections of the pancreas and the organs of the biliary system, a thorough examination of the gallbladder and extrahepatic bile ducts should be a mandatory stage of intraoperative diagnosis in acute pancreatitis.

Thus, to select the object, methods and volume of surgical intervention during the intraoperative examination, it is necessary to consistently solve the following tasks:

exclude other forms of “acute abdomen”;
identify characteristic morphological signs of acute pancreatitis;
determine the form of damage to the pancreas and retroperitoneal tissue;
establish the prevalence of damage to the pancreas and retroperitoneal tissue;
assess the color, volume, locations of accumulations of peritoneal pancreatogenic exudate;
assess pancreatogenic damage to other organs and tissues;
subject to a gentle inspection of the organs of the biliary system.

3.2.2. Possible errors in intraoperative diagnosis of severe acute pancreatitis

The condition of the pancreas and the retroperitoneal tissue immediately surrounding it can be examined through the lesser omentum, gastrocolic ligament and root of the mesentery of the transverse colon.

The least traumatic is an approximate assessment of the condition of the pancreas by examining and palpating the tissue at the “root” of the mesentery of the transverse colon. Directly adjacent to it is parapancreatic tissue along the anterior surface of the head, the lower edge of the body and tail. Of the sections of the pancreas, the head is the most accessible for examination through the mesocolon. In severe acute pancreatitis, intraoperative revision of the mesenteric root can lead to its perforation caused by infected parapancreatic necrosis, which is technical error. Creating a window in the mesentery to expose and inspect the pancreas is technical error during intraoperative revision.

The best conditions for intraoperative revision are provided by access to the omental bursa through a window in the gastrocolic ligament, which is cut between the clamps and securely sutured. The strands of the transected gastrocolic ligament should not be short - otherwise their ligation can lead to necrosis of the wall of Coli transversi, which is a technical error that can lead to the development of a transverse colon fistula. After dissection lig. gastrocolicum at the bottom of the omental bursa, you can palpate, and under favorable conditions, observe, part of the pancreas from the medial zone of the head to the tail. A wide exposure of the wound will allow visual inspection of the tail. Most of the anterior surface of the head of the pancreas, covered with the mesocoli root, is not accessible to direct inspection. Only after dissection of its upper layer and reduction of the hepatic angle of the colon is the hidden part of the head exposed. The dorsal surface of the pancreas should be considered practically inaccessible to inspection and no attempts should be made to mobilize it except in force majeure circumstances (for example, bleeding from the superior or inferior mesenteric and portal veins). Damage to large venous trunks forming the portal vein behind the isthmus of the pancreas is gross technical error, which usually leads to bleeding, hemorrhagic shock and death in the immediate postoperative period.

The lower surfaces of the body and tail are examined after dissecting their parietal peritoneum along the lower edge. Let us emphasize once again that such techniques are justified in a very small contingent of patients suffering from the most severe and complicated forms of destructive pancreatitis and that their use without sufficient grounds is unacceptable.

In the 80-90s. of the last century, the “certificate of achievements” in pancreatic surgery were subtotal resections of this organ in order to reduce intoxication, which was achieved by eradicating massive foci of pancreatic necrosis. This mutilation tactic did not reduce mortality and is currently considered a gross tactical mistake in the surgical treatment of pancreatic necrosis.

During surgery for severe acute pancreatitis, it is possible intraoperative diagnostic error, as a result of which the surgeon has an exaggerated idea of the severity of morphological changes in the pancreas. This error is associated with the “light filter” and “deceptive curtain” effects, little known to doctors, first described by researchers from Romania (Leger L., Chiche B. and Louvel A.) in 1981. These authors noted that during a pathological examination of the pancreas specimens they resected, the prevalence and depth of necrosis turned out to be significantly less than the surgeon expected.

Reason intraoperative diagnostic The error was the reflection of light from the pancreatic parenchyma penetrating through the layer of hemorrhagic exudate and creating a “light filter effect”.

Another erroneous judgment about the volume of hemorrhagic pancreatic necrosis arose as a result of the fact that lymph flowing from the pancreas accumulates in the superficial lymphatic plexuses, where, as a result of a significantly higher concentration of histopathogenic substances, a relatively thin layer of black, necrotic parenchyma is formed. Moreover, the authors who described this phenomenon during the operation assessed the degree of damage to the pancreatic parenchyma as “total hemorrhagic necrosis. Only during the autopsy or examination of the resected specimen did it become clear that under a 5-7 mm layer of slate-black necrotic parenchyma, light yellow tissue of slightly changed pancreas was found. This allows us to qualify the intraoperative study data as diagnostic error during intraoperative diagnosis.

The previously practiced opening of the anterior peritoneum allowed the outflow of exudate, which caused a false impression of the nature of the damage to the pancreas. Insufficient awareness of the operator may lead to the assumption of the development of “total” pancreatic necrosis, because a layer of brown effusion in the anterior subcapsular tissue and a subsequent change in the color of the adipose tissue from red to brown and black, create the erroneous impression of “total hemorrhagic necrosis.” Currently, early opening of the tissue along the lower contour of the pancreas is not recommended, because promotes unnecessary trauma and opens the gates wider for the penetration of pathogenic intestinal flora.

From a modern point of view, digital or instrumental revision of the omental bursa before the development of infected parapancreatic necrosis is not indicated and is considered erroneous.

Pathological changes in different parts of the pancreas may not coincide. Therefore, to establish the correct operational diagnosis, if this is absolutely necessary, the head, body, and tail of this organ must be examined. The listed morphological phenomena are the source false assumptions about “total” or subtotal pancreatic necrosis,” whereas in reality, under a layer of necrotic peritoneum and anterior subcapsular tissue, damage to the pancreas can be much less terrifying, as is often mistakenly assumed.

We also consider superficial and rough intraoperative examination of the pancreas to be technical errors in intraoperative diagnostics.

3.2.3. Diagnostic errors in severe acute pancreatitis

An analysis of medical histories of those who died from acute pancreatitis showed that various medical errors have a significant impact on the course and outcome of this disease. They were noted in 93.5% of the dead, and in 26% of observations their significance in the death of the patient was very large. Eliminating only the most serious errors would reduce the mortality rate from this disease.

An analysis of medical histories of patients suffering from severe acute pancreatitis showed that in some cases this disease may be undiagnosed or misinterpreted, proceeding unrecognized under the “clinical masks” of various diseases, both abdominal and extra-abdominal.

Clinical symptoms of necrotizing pancreatitis are often atypical.
We have established that some forms of acute pancreatitis are quite characterized by “clinical masks” of other forms of acute inflammatory diseases of the abdominal organs.

In this publication, dedicated to the various options and nuances of the clinical picture of acute pancreatitis, we considered it appropriate to include an analysis of such cases. A similar study in acute appendicitis was conducted by Rotkov I.L. (1988). The materials of this author analyzed the “clinical masks” of acute appendicitis, which occurred “under the flag” of other forms of ACPD, including acute pancreatitis. Similar comparisons have not previously been made in acute pancreatitis.

Reviewing the medical histories of the deceased in non-specialized surgical hospitals, we were convinced that certain phases of development and forms of severe acute, usually destructive pancreatitis are characterized by specific clinical “masks”.

We analyzed the materials of the file we created of lethal outcomes of severe acute pancreatitis, during the study of which we identified 581 observations, the symptoms of which had a certain topographic and organ specificity, which constituted 64.6% of all studied lethal outcomes. Moreover, alternating sequences of various clinical images were often noted, which could justifiably be called "the theater of clinical masks of pancreatic necrosis"...This is not an empty play on words, because... the polymorphism of clinical manifestations of pancreatic necrosis is actually fraught with diagnostic errors and, consequently, leads to an increase in the number of deaths.

Combinations of variants of “atypical” symptoms were often identified.

A medical error can pass without a trace for the patient, or can lead to tragic consequences. But the reason for the error is not always the doctor’s incompetence or his unwillingness to work. Sometimes things are much more complicated. Read more about the causes of medical errors in the article.
Recently, the topic of medical errors has become increasingly popular in the media. These words often hide real crimes. For example, recently in one of the television programs they talked about a drunk doctor. But there is nothing to discuss here. This is obviously a criminal act and is subject to criminal prosecution. It’s better to talk about real medical errors that happened by accident.

Causes of medical errors

There are many reasons for medical errors. The most common of them is incorrect diagnosis. The second group includes errors in treatment tactics. They are closely related to the errors of the first group. An incorrect diagnosis leads to incorrect treatment. The third group is organizational errors. The most striking example is the liquidation of the pediatric service and the widespread introduction of general practitioners, promoted by the former Minister of Health of the Russian Federation Mikhail Zurabov. And finally, the fourth group is deontological errors, that is, errors in the doctor’s behavior.

Now about the objective reasons that lead to medical errors. One of them is the emergence of new, previously unknown diseases, such as, for example, AIDS or malignant pneumonia. Naturally, doctors will make mistakes! Diagnosis is generally difficult. The limitations and inaccuracy of medical knowledge take their toll.

Recognizing a disease can be difficult, because it can occur in an atypical manner, not at all as described in textbooks. In addition, it happens that the same disease manifests itself differently in two patients. And the difficulties of diagnosis in young children!

Prevention of medical errors

Medical errors cannot be avoided. However, it is possible and should reduce their number. But how? The main way is a systematic analysis of errors in each medical institution. In a good clinic, any mistake, even the smallest one, by the doctor, which did not entail consequences for the patient, will be sorted out the very next day. And serious mistakes are discussed at a hospital conference with the obligatory participation of students. It does not matter who admitted them - the professor, associate professor, head of the department or the doctor on duty. The worst thing that can happen is if the doctor hid his mistake (this is easy to do in medicine), and after a certain amount of time his colleague repeated the same mistake only because it was not sorted out in time.

The concept of medical errors, their classification.

As in any other complex mental activity, in the diagnostic process incorrect hypotheses are possible (and making a diagnosis means putting forward hypotheses that are either confirmed or rejected in the future), and diagnostic errors are possible.

In this chapter, the definition and essence of the very concept of “medical errors” will be analyzed, their classification will be given, the causes of medical errors, in particular diagnostic errors, will be considered, and their significance in the course and outcome of diseases will be shown.

Unfavorable outcomes of diseases and injuries (deterioration of health, disability, even death) are due to various reasons.

The first place should be given to the severity of the disease itself (malignant neoplasms, myocardial infarction, other forms of acute and exacerbation of chronic coronary heart disease and many others) or injuries (incompatible with life or life-threatening injuries, accompanied by severe shock, bleeding and other complications , III-IV degree burns of significant surfaces of the body, etc.), poisoning with various substances, including drugs, as well as various extreme conditions (mechanical asphyxia, exposure to extreme temperatures, electricity, high or low atmospheric pressure), etc.

Late seeking of medical help, self-medication and treatment from healers, and criminal abortions also often lead to serious consequences for the health and life of people.

A certain place among the adverse outcomes of diseases and injuries is occupied by the consequences of medical interventions, late or erroneous diagnosis of a disease or injury. This may result from:

1. Illegal (criminal) intentional actions of medical workers: illegal abortion, failure to provide medical care to a patient, violation of rules specifically issued to combat epidemics, illegal distribution or sale of potent or narcotic substances and some others.

2. Illegal (criminal) careless actions of medical workers that caused significant harm to the life or health of the patient (negligence in the form of failure to perform or dishonest performance of their official duties; grave consequences as a result of gross violations of diagnostic or therapeutic techniques, non-compliance with instructions or instructions, for example, transfusion of blood of a different group due to violations of instructions on determining blood group), when the doctor or paramedical worker had the necessary capabilities to take correct actions to prevent the development of complications and associated consequences.

Criminal liability in these cases occurs if a direct causal link is established between the action (inaction) of a medical worker and the grave consequences that occur.

3. Medical errors.

4. Accidents in medical practice. Not a single person, even with the most conscientious performance of his duties, in any profession or specialty, is free from erroneous actions and judgments.

This was recognized by V.I. Lenin, who wrote:

“The smart one is not the one who doesn’t make mistakes. There are no such people and there cannot be. Smart is the one who makes mistakes that are not very significant and who knows how to correct them easily and quickly.” (V.I. Lenin - Childhood disease of “leftism” in communism. Collected works, ed. 4, vol. 31, Leningrad, Politizdat, 1952, p. 19.)

But the doctor’s mistakes in his diagnostic and therapeutic work (and preventive, if it concerns a sanitary doctor) are significantly different from the mistakes of a representative of any other specialty. Suppose the architect or builder made a mistake when designing or building the house. Their mistake, although serious, can be calculated in rubles, and, ultimately, the loss can be covered in one way or another. Another thing is a doctor’s mistake. The famous Hungarian obstetrician-gynecologist Ignaz Emmelweis (1818–1865) wrote that with a bad lawyer, the client risks losing money or freedom, and with a bad doctor, the patient risks losing his life.

Naturally, the issue of medical errors worries not only the doctors themselves, but also all people, our entire public.

When analyzing medical errors, it is necessary to define them. It should be noted right away that lawyers do not have the concept of “medical error” at all, because error is not a legal category at all, since it does not contain signs of a crime or misdemeanor, that is, socially dangerous acts in the form of action or inaction that caused a significant (crime) or minor (misdemeanor) harm to the legally protected rights and interests of an individual, in particular health or life. This concept was developed by doctors, and it should be noted that at different times and by different researchers, different content was put into this concept.

Currently, the following definition is generally accepted: a medical error is a conscientious error of a doctor in his judgments and actions, if there are no elements of negligence or medical ignorance.

I.V. Davydovsky et al. (Davydovsky I.V. et al. Medical errors. Great Medical Encyclopedia. M., Sov.encyclopedia, 1976, vol. 4, pp. 442–444.) give the same essentially definition, but in slightly different words: “...a doctor’s mistake in the performance of his professional duties, which is the result of an honest mistake and does not contain a crime or signs of misconduct.”

Consequently, the main content of this concept is error (incorrectness in actions or judgments), as a consequence of an honest mistake. If we talk, for example, about diagnostic errors, this means that the doctor, having questioned and examined the patient in detail using methods available under certain conditions, nevertheless made a mistake in the diagnosis, mistaking one disease for another: in the presence of symptoms of an “acute abdomen”, he considered that they indicate appendicitis, but in fact the patient has developed renal colic.

Questions to consider: Are medical errors inevitable? What medical errors occur in medical practice? What are their reasons? What is the difference between medical errors and illegal actions of a doctor (crimes and misdemeanors)? What is liability for medical errors?

Are medical errors inevitable? Practice shows that medical errors have always occurred, since ancient times, and they are unlikely to be avoided in the foreseeable future.

The reason for this is that the doctor deals with the most complex and perfect creation of nature - with man. The very complex physiological, and even more so, pathological processes occurring in the human body have not yet been fully studied. The nature of even pathological processes of the same type in clinical manifestations (for example, pneumonia) is far from clear; the course of these changes depends on many factors both within the body and outside it.

The diagnostic process can be compared to solving a multifactorial mathematical problem, an equation with many unknowns, and there is no single algorithm for solving such a problem. The formation and substantiation of a clinical diagnosis is based on the doctor’s knowledge of the etiology, pathogenesis, clinical and pathomorphological manifestations of diseases and pathological processes, the ability to correctly interpret the results of laboratory and other studies, the ability to fully collect an anamnesis of the disease, as well as taking into account the individual characteristics of the patient’s body and related characteristics the course of his disease. To this we can add that in some cases the doctor has little time (and sometimes does not have enough opportunities) to examine the patient and analyze the data obtained, and the decision must be made immediately. The doctor will have to decide for himself whether the diagnostic process is over or should continue. But in fact, this process continues throughout the observation of the patient: the doctor is constantly looking for either confirmation of his diagnosis hypothesis, or rejects it and puts forward a new one.

Hippocrates also wrote: “Life is short, the path of art is long, opportunity is fleeting, judgment is difficult. Human needs compel us to decide and act.”

With the development of medical science, the improvement of existing ones and the emergence of new objective methods for establishing and recording processes occurring in the human body, both normally and in pathology, the number of errors, in particular diagnostic ones, is decreasing and will continue to decrease. At the same time, the number of errors (and their quality) due to insufficient qualifications of the doctor can be reduced only with a significant increase in the quality of training of doctors in medical universities, improvement in the organization of postgraduate training of doctors and, especially, with the purposeful independent work of each doctor to improve his skills. professional theoretical knowledge and practical skills. Naturally, the latter will largely depend on the personal, moral and ethical qualities of the doctor, his sense of responsibility for the assigned work.

CHAPTER II

DIAGNOSTIC THINKING:

ABOUT PSYCHOLOGICAL CAUSES OF MEDICAL ERROR

2.1. The concept of medical errors, their classification.

Objective and subjective causes of medical errors.

Above, we discussed the psychological foundations of communication between a doctor and a patient, on which the success of all diagnostic work of a doctor largely depends.

As in any other complex mental activity, in the diagnostic process incorrect hypotheses are possible (and making a diagnosis is the formulation of hypotheses that are either confirmed or rejected in the future), diagnostic errors are possible.

Unfavorable outcomes of diseases and injuries (deterioration of health, disability, even death) are due to various reasons.

The first place should be given to the severity of the disease itself (malignant neoplasms, myocardial infarction, other forms of acute and exacerbation of chronic coronary heart disease and many others) or injuries (incompatible with life or life-threatening injuries, accompanied by severe shock, bleeding and other complications , burns III– IV degrees of significant surfaces of the body, etc.), poisoning with various substances, including medicinal ones, andalso various extreme conditions (mechanical asphyxia, exposure to extreme temperatures, electricity, high or low atmospheric pressure), etc.

Late seeking of medical help, self-medication and treatment from healers, and criminal abortions also often lead to serious consequences for the health and life of people.

A certain place among the adverse outcomes of diseases and injuries is occupied by the consequences of medical interventions, late or erroneous diagnosis of a disease or injury. This may result from:

Criminal liability in these cases occurs if a direct causal link is established between the action (inaction) of a medical worker and the grave consequences that occur.

3. Medical errors.

4. Accidents in medical practice. Not a single person, even with the most conscientious performance of his duties, in any profession or specialty, is free from erroneous actions and judgments.

This was recognized by V.I. Lenin, who wrote:

“The smart one is not the one who doesn’t make mistakes. There are no such people and there cannot be. Smart is the one who makes mistakes that are not very significant and who knows how to correct them easily and quickly.” (V.I. Lenin – The childhood disease of “leftism” in communism. Collection works, ed. 4, t. 31, L., Politizdat, 1952, p. 19.)

But the doctor’s mistakes in his diagnostic and therapeutic work (and preventive, if it concerns a sanitary doctor) are significantly different from the mistakes of a representative of any other specialty. Suppose the architect or builder made a mistake when designing or building the house. Their mistake, although serious, can be calculated in rubles, and, ultimately, the loss can be covered in one way or another. Another thing– doctor's mistake. The famous Hungarian obstetrician-gynecologist Ignaz Emmelweis (1818– 1865) wrote that with a bad lawyer the client risks losing money or freedom, and with a bad doctor the patient risks losing his life.

Naturally, the issue of medical errors worries not only the doctors themselves, but also all people, our entire public.

Currently, the generally accepted definition is: medical error– This is a conscientious error of the doctor in his judgments and actions, if there are no elements of negligence or medical ignorance.

I. V. Davydovsky et al. (Davydovsky I. V. et al.Medical errors. Big medical encyclopedia. M., Sov. Encyclopedia, 1976, vol. 4, p. 442– 444.) give the same essentially definition, but in slightly different words: “... a doctor’s mistake in the performance of his professional duties, which is the result of an honest mistake and does not contain a crime or signs of misconduct.”

Are medical errors inevitable? Practice shows that medical errors have always occurred, since ancient times, and they are unlikely to be avoided in the foreseeable future.

The reason for this is that the doctor is dealing with the most complex and perfect creation of nature– with a person. The very complex physiological, and even more so, pathological processes occurring in the human body have not yet been fully studied. The nature of even pathological processes of the same type in terms of clinical manifestations (for example, pneumonia) is far from clear; the course of these changes depends on many factors contained both within the body itself and outside it.

Hippocrates also wrote: “Life is short, the path of art is long, opportunity is fleeting, judgment is difficult. Human needs compel us to decide and act.”

What are the causes of medical errors?

These reasons can be divided into two groups:

1. Objective, i.e., independent of the doctor himself and the degree of his professional training.

2. Subjective, directly dependent on the knowledge and skills of the doctor, his experience.

Among the objective reasons, one should point out the insufficient knowledge of the etiology and clinic of a number of diseases, in particular, rare ones. But the main objective reasons for medical errors are the lack of time to examine a patient or victim of injury (in urgent cases requiring immediate decision and medical intervention), the lack of necessary diagnostic equipment and equipment, as well as the atypical course of the disease, the presence of two or even more diseases. I.V. Davydovsky said this well: “... medicine is not a technique where exact sciences dominate– physics, mathematics, cybernetics, which are not the basis of a doctor’s logical operations. These operations, like the research itself, are especially complex because it is not an abstract disease that lies on a hospital bed, but a specific patient, that is, there is always some kind of individual refraction of the disease... the main, most objective reason for medical errors and errors is rooted in the individual factor. no guidance, no experience can guarantee the absolute infallibility of a doctor’s thoughts and actions, although, as an ideal, this remains our motto.”

It would be wrong to see in this statement by the famous scientist, who devoted more than half a century to the study of errors in the professional activities of doctors, some kind of justification for the errors and omissions made by doctors, an attempt to justify them with objective reasons. In his other works, I. V. Davydovsky analyzes and summarizes the causes of errors, which are the most common,– subjective.

The most common errors are in the diagnosis of diseases. S.S. Weil (Clinical diagnostic errors. Ed. S. S. Vailya. L., 1969, p. 6.) analyzes in detail their reasons, both subjective and objective. He points to the following subjective reasons:

1. Poor history-taking and not fully thought-out use of it.

2. Insufficient laboratory and x-ray examinations, incorrect conclusions of radiologists and insufficient critical attitude of clinicians to these conclusions.

Speaking about this, by the way, frequent reason, it should be noted that both radiographs and laboratory preparations themselves, such as blood smears, histological preparations, very objectively reflect this or that phenomenon: they record a fracture, ulcer, tumor or other pathological phenomena, deviations in the composition of blood cells, etc. But the assessment of these changes is subjective and depends on the doctor’s knowledge and experience. And, if this knowledge is not enough, then errors may occur in assessing the detected changes, which can lead to an incorrect diagnosis.

3. Incorrect organization of consultations, in particular correspondence, without the participation of the attending physician, consultations, underestimation or overestimation of the consultants’ conclusions.

4. Inadequate generalization and synthesis of data from the medical history, symptoms of the disease and examination results of the patient, inability to use all this data in relation to the characteristics of the course of the disease in a particular patient, especially when its course is atypical. To the subjective reasons for erroneous diagnosis that S.S. Weil lists, one more should be added: failure to carry out the minimum required research, as well as other research that could have been carried out.

We gave only subjective reasons. Analyzing them, it is easy to notice that in most of them we are talking not only about the incorrect actions of the doctor, as a consequence of his insufficient qualifications, but also about the failure to perform actions required for the doctor. Thus, neglect of medical history cannot be justified by insufficient qualifications and little experience, non-use opportunities for consultation with experienced doctors, failure to conduct those laboratory or functional studies that could have been performed. In such cases, we may be talking about the presence of elements of negligence in the actions of the doctor, and there will be no reason to evaluate the consequences of these actions as a medical error. What will be said in Chapter II of this manual about the influence of the individual psychological characteristics of the doctor on the diagnostic process is directly related to the occurrence of diagnostic errors for subjective reasons. In particular, this applies to such qualities as methods of obtaining, storing and processing information received by a doctor during the diagnostic process, the degree of sensitivity of the doctor’s analyzing systems, the characteristics of the doctor’s memory, the properties of his attention, switching, stability of attention, etc.

From the above, it logically follows that a measure to prevent diagnostic errors should be the constant professional improvement of a doctor (primarily in the form of self-improvement), in increasing his knowledge and practical skills. Along with this, the doctor must be able to admit his mistakes and analyze them in order to avoid similar ones in his future work. An example in this regard was set by the great Russian surgeon II. I. Pirogov, who made his mistakes public, rightly believing that it was possible “... by truthfully openly admitting one’s mistakes and by revealing the intricate mechanism, one can save one’s students and novice doctors from repeating them.”

In the occurrence of diagnostic errors, the deontological qualities of a doctor: his attentiveness and conscientiousness, willingness to consult with a more experienced doctor, sense of responsibility.

Practice shows that diagnostic errors are made not only by young, but also by experienced doctors with high professional training and extensive work experience. But they make mistakes in different ways. Young doctors make mistakes more often and in fairly simple, from a diagnostic point of view, cases, while experienced doctors make mistakes in complex and confusing cases. I.V. Davydovsky wrote: “The fact is that these (experienced) doctors are full of creative daring and risk. They do not run away from difficulties, i.e. cases difficult to diagnose, but boldly meet them halfway. For them, high-ranking representatives of medicine, the goal– save the patient– justifies the means."

What medical errors occur in practice? Currently, most researchers distinguish the following main types of medical errors:

1. Diagnostic.

2. Errors in choosing a method and carrying out treatment (they are usually divided into therapeutic-technical and therapeutic-tactical).

3. Errors in the organization of medical care. In addition to those listed, some authors also identify errors in maintaining medical records. If we talk about these errors, then in their occurrence, as well as in the occurrence of medical and technical errors, objective reasons should be completely excluded. Here we can only talk about the shortcomings of the doctor’s training, i.e., the subjective reason for the occurrence of these errors.

Our task included an analysis of diagnostic errors and their causes, since they are more common and, in most cases, determine treatment errors, although in some cases treatment errors occur even with a correct diagnosis.

A large literature is devoted to a detailed analysis of all types of medical errors.

(Errors in clinical diagnosis, edited by S. S. Weil, L., 1969, p. 292;

N. I. Krakovsky. Yu. Ya. Gritsmag– Surgical errors. M., 1967, p. 192;

S. L. Libov - Errors and complications in heart and lung surgery, Minsk 1963, p. 212;

V. V. Kupriyanov, N. V. Voskresensky– Anatomical variants and errors in medical practice, M., 1970, p. 184;

A. G. Karavanov, I. V. Danilov– Errors in the diagnosis and treatment of acute diseases and injuries of the abdomen, Kyiv, 1970, p. 360;

M. R. Rokitsky - Errors and dangers in pediatric surgery, M., 1979, p. 183; Diagnostic and therapeutic errors of the doctor. Sat. scientific works, Gorky, 1985, p. 140.)

What is liability for medical errors?

It was already noted above that in cases of medical errors in which there are no elements of negligence or medical ignorance, the question of the doctor’s legal (administrative or criminal) liability does not arise. However, in all cases there remains moral responsibility. A true humanist doctor with a heightened sense of duty cannot help but think about the mistake he has made and its consequences, cannot help but worry, and for every mistake his conscience pronounces a sentence on him, and this sentence of conscience can be heavier than a human sentence.

Each error must be analyzed by the medical team. It is necessary to establish the causes and conditions for the occurrence of an error in each specific case. When analyzing and analyzing the causes of errors, it is necessary to resolve the question: could the doctor, under objectively prevailing conditions, with his qualifications and conscientious attitude to the matter, avoid the error? In medical institutions, this is done at meetings of treatment and control commissions and clinical-anatomical conferences with the participation of pathologists or forensic experts. Such conferences are a good school not only for training, but also for educating doctors and other medical workers.

The outstanding Soviet clinician and scientist I. A. Kassirsky, in his monograph “On Healing,” which every doctor must carefully study, wrote: “Errors - the inevitable and sad costs of medical practice, errors are always bad, and the only optimal thing that follows from the tragedy of medical errors is that they teach and help in the dialectics of things to prevent them from happening... they carry in their being the science of not making mistakes, and it is not the doctor who makes a mistake who is guilty, but the one who is not free from cowardice to defend it.” (I. A. Kassirsky– “On healing” – M., Medicine, 1970, p. 27.)

Accidents in medical practice.

Only a person guilty of committing a crime, i.e., who intentionally or carelessly committed a socially dangerous act provided for by law, is subject to criminal liability and punishment.

According to Soviet laws, socially dangerous consequences of a person’s actions (or inaction) cannot be imputed if he did not and could not foresee these socially dangerous consequences.

Here we can talk about a case, i.e. an event that is not caused by anyone’s intent or carelessness, and therefore there is no intentional or careless guilt in the actions (inaction) of a person. In medicine, it is customary to talk about accidents in medical practice, which are understood as such unfavorable outcomes of medical intervention (during diagnosis or treatment), which, according to modern medical science, could not be objectively foreseen and, therefore, could not be prevented.

Accidents in medical practice occur as a result of unfavorable circumstances, and sometimes from the individual characteristics of the patient’s body, which do not depend on the will or actions of medical workers.

The circumstances under which accidents occur and the reasons that cause them are rare. Thus, accidents include severe allergies, even the death of the patient, due to intolerance to the drug (usually antibiotics) upon the patient’s first contact with it; the so-called “anesthesia death” with indicated and impeccably correctly administered anesthesia. The causes of “anesthesia death” are not always established even with pathoanatomical corpse examination. In such cases, the reasons for unfavorable outcomes lie in the characteristics of the patient’s functional state, which could not be taken into account even with the most conscientious actions of the doctor.

If the unfavorable outcome of a diagnostic or therapeutic intervention was caused by insufficient, careless or incorrect actions of a doctor from the point of view of medical science, then there are no grounds for recognizing the results of these actions as an accident.

// L.M. Bedrin, L.P. Urvantsev Psychology and deontology in the work of a doctor. – Yaroslavl, 1988, P.28-36

See also: