What are the subjective errors of the doctor. Ways to prevent medical errors

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

IN: As far as I understand, Alexander Vladimirovich, this is such a painful topic that God forbid you and I meet within an hour of conversation. Because 80 percent of medical errors go unpunished (according to your own statistics) ... Do you deal with those very mistakes and try to figure it out and find right and wrong?

AS: I think yes, it is. Moreover, 80 percent is such a very gentle statistic, because in reality, if we talk based on the statistics of the federal compulsory health insurance fund, then we have about 10 percent of assistance with, and this is 40 million hospitalizations in the inpatient unit, respectively

4 million defects. Approximately 3,000 cases a year reach 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, or the law. And such assistance is 10 percent from the assessment of insurance companies. Experts carry out 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 a revelation. Nothing of the sort, because the insurers are simply fined small penalties to the OTC. And patients are not even informed about this, about these defects. Imagine, revealing that there was a medical error, and not informing the person about it!

IN: And what about you, tell me, if a person does not know about it, how is this medical error revealed?

AS: It doesn't show up at all. People often seem to understand that something was wrong, but they don’t have this act of the insurance company, so, accordingly, they either don’t know, or they walk around, buzz around, try to explain, prove it in some way 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, a leg, an organ there. I mean, these are serious things.

IN: And to understand whether the doctors are to blame or somehow the circumstances have developed?

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

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

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 confronted with some egregious facts.

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

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

AS: Yes. "Let's talk about terms." Unfortunately, the system is insane, one of the most inert. Here, with all the shortcomings of the socialist system, there are some relations that have been added that are not market-oriented.

IN: Crisis, post-crisis problems.

AS: Absolutely right. Health care right now is monstrous in fact from all points of view. He really needs to be treated, loved the way he is, give him money, fill him with care from the state, otherwise we will all suffer and be afraid of this.

IN: Wait, Alexander Vladimirovich, you yourself said that you used to think that the healthcare system had no money, it needed help, money, but now you 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, they are coming, 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 have their own healthcare system). You immediately understand that there, in the pockets, there is still oh-she-she, 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 taken care of, will treat the patient much better than a doctor in a glass building and concrete with millions of equipment. But with a salary of 15 thousand, and, moreover, working on 2-3 shifts, 2-3 jobs, that the first doctor simply by his care will help the patient much more than this doctor, who is simply dangerous to go to. He is a tired man, abandoned, not having time to learn modern technologies.

IN: Are you talking about someone who sits in a hut, gets 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 does not have time for the patient. Well, this is such a surrogate of our healthcare system born, this is not a doctor.

IN: Do you think it's all about the salary?

AS: I think it's all about the lack of care from the state, and salary is one of the most serious indicators here.

IN: And how to determine where the big salary is, where is the small one?

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

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

AS: Well, what they live on is another question, because in reality 5 thousand ... The doctor should sit in his place, there from 8 o'clock in the morning until three and receive a good salary, not less than 2 thousand dollars.

IN: And who determined that it should be 2 thousand dollars?

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

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

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

IN: That is, the same 2 thousand dollars.

AS: It's already money, yes. For Moscow, let's say, 60 thousand is probably the minimum bar that a doctor should receive.

IN: And this should he receive in budgetary organizations?

AS: It's not that 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: And why is there a private one in Europe?

AS: Because healthcare developed differently there. You see, the fact is that creating a public health system is insanely expensive. Just, you know, because it's just very expensive to build a huge number of institutions at the right scale. We in the Soviet Union did this, and now we are trying to give these institutions back to private owners, that is, to take a step back. This is sheer nonsense.

The state has announced that it will give public institutions in concession to private organizations. Here. Accordingly, a surrogate will appear in place of a state organization, a private state partnership that will earn money on everything that moves.

IN: And before that, the private ones did not make money on everything that moves?

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 such an incomprehensible creation will appear in the place of state clinics.

IN: Will it appear instead of district polyclinics?

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

IN: What departmental medical organizations?

AS: It's about… Well, let's just say that the MedSi network pretty much exists in this way. Yes, ministries.

IN: That is, the 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 polyclinics and dispensaries.

AS: You see, in such cases I always remember this very “Ivan Vasilyevich is changing his profession”, “what are you doing, royal muzzle, squandering the people's lands”. And who gave them the right to get rid of state property? These people earned for themselves, for our taxes.

IN: What do you mean?

AS: What do you mean?

IN: What kind of people earned for themselves?

AS: Folks, this is the people's property.

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

sanatoriums, dispensaries

AS: I'm talking about the public health system, I'm only interested in it. When the ministry gets rid of public health facilities, it annoys me, because, in fact, they were built with public money. Why are they suddenly getting rid of them? There must continue to be medical care. Some high-tech centers are being built. That is, we fuse one thing, we build another. There will never be enough money, dear comrades.

IN: We are actually sawing the third one.

AS: Yes, yes. You see, this is actually insane. Moreover, all this is done in such a closed, secret order, that is, "but we decided." And what did you decide? And who gave you the right to do so? Because we have the 41st article of the Constitution, the state guarantees the assistance of state municipal institutions free of charge. Well, then, if you please, implement the Constitution. Why are you starting to play some games with public-private partnerships there?

The state institution was rented out, and there arose another person, a public-private partnership, another already, not a state institution. The status is different, you understand, 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 off, left and no longer owe anything to anyone, no free help. Therefore, formally, the requirement of the Constitution does not apply to him.

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

AS: We are only talking about medicine. I'm talking about Article 41 of the Constitution, which says that medical assistance 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 must adhere to. That is, do we have any strict standards for doctors in how they should carry out diagnostics, examination, treatment, postoperative measures?

How strictly regulated is it?

AS: From 2004-4 to 2007, about 700 standards were adopted, under the current law they are mandatory, although the Ministry of Health is constantly floating 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 often use this in court in the following way. We take a medical history, compare it with the standard, that is, there is already a diagnosis in the medical history, you take ...

IN: Which is maybe 30 percent wrong.

AS: You know, in that 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. Indeed, in this situation, the medical history is almost the only source of information, evidence and information. And the absurdity of the situation lies in the fact that we often punish doctors not for what they did, but for what they wrote. Because writing 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 starts to curse there. Guys, what are you up to? There is none of your fault in this. Have you broken anything? No. Why are you hiding and writing some nonsense in the medical history? Just to hide that there was some kind of anaphylactic shock. He was? Was.

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

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

And here, when there, for two hours, he tries to resuscitate him, having neither the skills nor the equipment for this, and the person dies, here, excuse me, the failure to provide medical assistance, which led to death.

IN: That's why they try to hide it.

AS: It's not that that's being hidden. They begin to invent some kind of bleeding, something absolutely crazy. Here. Because there is no simple knowledge that if you did everything right in this part and you should not have taken allergy tests, it’s just not possible to do it for all drugs, then it’s not your fault.

IN: Alexander Vladimirovich, when an anaphylactic shock occurs somewhere in a dental clinic from an injection of the simplest, yes, painkiller, this is one story. And when this happens in the operating room, as was the case with the patient in 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.

ID: At the same time, there, accordingly, probably, some tests, some tests should take place before the operations.

AC: This is an insanely difficult question. Firstly, indeed, the fact is that anaphylaxis is such a thing that it depends little on the amount of the injected substance. And an allergic reaction occurs immediately and has a systemic character. Secondly, the fact is that if you think about dentistry, then, strictly speaking, we always have violations of the law here, and even criminal ones in general, according to Article 235. The fact is that dentists, of course, do not have the right to engage in anesthesiology.

St. Petersburg Research
institute of emergency care named after prof. I.I. Dzhanelidze

CHARACTERISTIC MEDICAL ERRORS
IN THE TREATMENT OF SEVERE ACUTE PANCREATITIS

(a guide for doctors)

Part 1. Typical errors and their classification.

St. Petersburg, 2005

INTRODUCTION

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

Before turning 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 from medical errors in US hospitals ["Science and life. 2005 No. 5 p. 100.]. However, the US is 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 allowed, which is always fraught with the possibility of making dangerous mistakes in diagnosis and treatment.
The literature on medical malpractice 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 methodologists and students: clinical residents, graduate students and interns.

Let us 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 of interest to us is very scarce. There are practically no publications that discuss errors in the diagnosis and treatment of severe acute pancreatitis. The lack of publications that consider typical errors is to some extent made up 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 generally unproductive and is limited to rare descriptions of special cases of medical and diagnostic errors.

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

Definitions of Medical Error

Here are some 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 the violation of the implementation of medical technologies, increasing or not reducing the risk of progression of the patient's disease, as well as the risk of new pathological process. Non-optimal use of healthcare resources is also referred to as "medical error" (Komorovskiy Yu.T., 1976).

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

"Medical error" is defined as a preventable, objectively wrong action (or inaction) of a doctor that contributed or could contribute to the disruption of medical technologies, increase or not decrease the risk of progression of a patient's disease, the possibility of a new pathological process, as well as suboptimal use health care resources and ultimately lead to consumer dissatisfaction in health care”.

Most of the above definitions were taken from the official website of the Territorial Compulsory Medical Insurance Fund, which published 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.
In modern, especially foreign, literature, an indicator of the quality of medical care is used as an integrating indicator.

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

Treatment and diagnostic errors are an objective factor that worsens the results of treatment. 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 therapeutic and diagnostic errors, orders, “protocols”, evidence-based recommendations, therapeutic and diagnostic algorithms, and, finally, standards have been developed in Russia and abroad, which are designed to reduce the frequency and danger of therapeutic and diagnostic errors made by prehospital and hospital doctors. stages of the ambulance service.

Based on the guidance documents developed by such organizations 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 real practice with the standards published in these guidance documents.

In the Northwestern Federal District of the Russian Federation, such a document is the document "Acute pancreatitis (Treatment diagnostic protocols) ICD-10-K85" [For the first time, a document regulating the scope and proper 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 Department of Health of the Executive Committee of the Leningrad City Council on July 14, 1988. Changes in the composition of proper 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 assessing the quality of diagnosis and treatment of acute pancreatitis, as well as qualifying errors in order to eliminate them and increase consumer satisfaction with the quality of medical care.

At the end of the XX and at the beginning of the XXI centuries. new theoretical concepts have appeared, new methods of diagnosis and treatment, also associated with the risk of developing previously unknown dangers, errors and complications.

Krakovsky N.I. and Gritsman Yu.Ya. (1967) refers to surgical errors all the actions of the surgeon that unwittingly caused or could cause damage 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, elaborate but overly detailed classification of medical errors. This author distinguishes between types, stages, causes, consequences and categories of errors. According to Komarovsky, the administrative aspect of doctor's mistakes ranges from "delusion" and "accident" to "misdemeanor" or "crime".

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

Komorovsky Yu.T. (1976) distinguishes between diagnostic, therapeutic 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 department, in the admissions department of a hospital, in the process of examination, diagnosis, establishing 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 "rubricator" 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; quality and formulation of diagnoses; difference between 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 the clinic, at the emergency station.

2.2. Stationary: preoperative, operational, postoperative.

2.3. Post-stationary: adaptive, convalescent, 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: adverse features of the patient and 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 medical treatment, disability, death.

1.1. Types of diagnostic errors

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

1.1.2. By the quality and formulation of diagnoses: unidentified(lack of diagnosis in the presence of the disease); false(the presence of a diagnosis in the absence of a disease); incorrect (mismatched in the presence of another disease); erroneous(there is no named disease of interest); viewed(the desired disease is not named); untimely (late, overdue); incomplete(the necessary components of the diagnosis are not named); inaccurate(poor wording and editing); ill-conceived(unsuccessful interpretation and arrangement of components of the diagnosis.

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

1.2. Types of medical errors

1.2.1. Are common: unindicated, incorrect, insufficient, excessive, belated treatment; incorrect and untimely correction of metabolism (water-salt balance, acid-base balance, carbohydrate, protein and vitamin metabolism); incorrect and untimely choice and dosage of medicines, physiotherapy procedures and radiation therapy; the appointment of incompatible combinations and the erroneous use of drugs, improper dietary nutrition.

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

1.2.3. Technical: lack of asepsis and antisepsis (for example, poor processing of the surgical field, additional infection), poor 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 drains, etc.

1.3. Types of organizational errors

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

1.3.2. Documentation: from incorrect execution of protocols for the operation of documentation, certificates, extracts from case histories, sick leaves; shortcomings and gaps in the design of outpatient cards, case histories, operating journal; defective registration logs and so on.

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 shortcomings of a doctor from moral and physical to insufficient professional competence.

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

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

3.1. Objective causes of diagnostic errors

3.1.1. Unfavorable features of the patient and the disease: old age, decrease or loss of consciousness, sudden excitement, extremely severe or terminal states, mental inferiority; simulation or dissimulation on the part of the patient and underestimation (anosognosia) or hyperbolization (aggravation) of the severity of the disease by the patient. , Diagnostic errors contribute to the state of drug or alcohol intoxication, senile dementia, mental illness, severe obesity, altered body reactivity, 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 associated symptoms of background and concomitant diseases, as well as various complications.

3.1.2. Unfavorable environment: poor lighting, heating, ventilation, lack of necessary equipment, tools, medicines, reagents, dressings; unsatisfactory work of the laboratory, lack of consultants, means of communication and transport; absence, inaccuracy and incorrectness of information on the part of 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 of early diagnosis; insufficient effectiveness of available treatments; limited possibilities of diagnostic and medical equipment.

All established diagnoses must be accompanied by the date of their discovery. Analyzes should be traced in dynamics with the identification of trends in the course of the pathological process.

The 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 execution of the preoperative conclusion(epicrisis), which includes the following information:

1. Motivated diagnosis;

2. Features of the patient and disease;

3. Operational access and planned operation;

4. Methods and means of anesthesia;

5. Informed consent of the patient or his proxies for the operation or other instrumental intervention, recorded in the medical history and signed by 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. When indications for emergency surgery are identified, a patient with an acute surgical disease of the abdominal organs must certainly undergo proper preoperative preparation, the composition, volume and duration of which depend on the specific circumstances. In diseases such as severe acute pancreatitis or peritonitis, diagnostic measures should be simultaneously accompanied by preoperative preparation, which is especially important in the treatment of patients with severe acute pancreatitis.

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

9. Some errors are due to the imperfection of 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 erroneousness of a doctor's professional actions is his compliance with 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 much larger amount of information that is important for the successful treatment of acute surgical diseases in general and acute pancreatitis in particular.

Given the importance of a thorough, accurate and, at the same time, sparing 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 in various forms of "acute abdomen" is the most important step 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 variety of its manifestations. In 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 is 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 carefully identify the morphological signs of the disease in all anatomical formations, as well as to 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 the pancreas in the retroperitoneal space;
multicomponent nature of the pathological process;
variety of types of tissue necrosis;
variability of morphological signs of acute pancreatitis;
dependence of the volume 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. Tasks and sequence of the survey

The task of intraoperative diagnostics in acute pancreatitis is to clarify the morphological and clinical forms and the prevalence 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 responsible 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 noted in the retroperitoneal tissue, omental sac, peritoneum, greater and lesser omentums and in other anatomical formations. Such components of local pathological reactions as parapancreatitis, paracolitis and paranephritis, peritonitis and omentobursitis, omentitis, ligamentitis in combination with concomitant acute biliary tract pathology, as a rule, are the main potential objects of surgical interventions. If in acute appendicitis the diagnosis unambiguously determines the nature of the operation, then in acute pancreatitis, additional information on the severity of all components of the pathological process is needed to resolve the issue of the operation technique and its volume. Therefore, an intraoperative examination of the abdominal cavity in acute pancreatitis should include an examination of all of the above formations, and the identified components of local pathological reactions should be detailed and accurate in the postoperative diagnosis.

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

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

A wide surgical exposure of the pancreas in some cases is a prerequisite in the struggle for the life of a patient with destructive pancreatitis, and sometimes adversely affects 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 widespread pancreatic and retroperitoneal destruction, mobilization of the pancreas is not justified. Moreover, it cannot be justified only by the need to examine this body.

Given the close anatomical and physiological relationships between the pancreas and the organs of the biliary system, a thorough examination of the gallbladder and extrahepatic biliary tract should be a mandatory step in intraoperative diagnosis in acute pancreatitis.

Thus, in order 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 lesions of the pancreas and retroperitoneal tissue;
to evaluate the color, volume, places of accumulations of peritoneal pancreatogenic exudate;
assess pancreatitis damage to other organs and tissues;
to subject the organs of the biliary system to a gentle revision.

3.2.2. Possible errors in intraoperative diagnosis of severe acute pancreatitis

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

The least traumatic is an approximate assessment of the state of the pancreas by examining and palpating the tissues at the “root” of the mesentery of the transverse colon. Parapancreatic tissue adjoins directly to it 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 mesocolon. In severe acute pancreatitis, intraoperative revision of the mesenteric root can lead to its perforation due to infected parapancreatic necrosis, which is technical error. Creation of a window in the mesentery for the purpose of exposure and revision of the pancreas is technical error during intraoperative revision.

The best conditions for intraoperative revision are provided by access to the omental bag through a window in the gastrocolic ligament, which is dissected 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 is fraught with the development of a fistula of the transverse colon. After dissection lig. gastrocolicum at the bottom of the stuffing bag can be palpated, and under favorable conditions, and observed, 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 pancreatic head, covered by the mesocoli root, is not directly visible. Only after dissection of its upper leaf and bringing down the hepatic angle of the colon, the hidden part of the head is exposed. The dorsal surface of the pancreas should be considered practically inaccessible to inspection and no attempt should be made to mobilize it, except for force majeure circumstances (for example, bleeding from the superior or inferior mesenteric and portal veins). Damage to large venous trunks that form 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 dissection of the parietal peritoneum along their lower edge. We 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 justification is unacceptable.

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

During surgery for severe acute pancreatitis, 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 little-known effects of the “light filter” and “deceptive curtain”, which were first described by researchers from Romania (Leger L., Chiche B. and Louvel A.) in 1981. These authors noted that in the pathoanatomical study of the pancreatic preparations resected by them, the prevalence and depth of necrosis turned out to be significantly less than the surgeon expected.

Cause intraoperative diagnostic error was the reflection of light from the parenchyma of the pancreas 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 the 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 dead black parenchyma is formed. At the same time, the authors who described this phenomenon, during the operation, regarded the degree of damage to the pancreatic parenchyma as “total hemorrhagic necrosis. Only during the autopsy or examination of the resected preparation, it turned out that under a 5-7 mm layer of slate-black necrotic parenchyma, a light yellow tissue of a slightly altered pancreas was found. This allows us to qualify the data of the intraoperative study as diagnostic error in intraoperative diagnostics.

The previously practiced opening of the anterior peritoneum made it possible to drain the exudate, which caused a false impression of the nature of the pancreatic lesion. Lack of 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 subsequent discoloration of the adipose tissue from red to brown and black give the erroneous impression of "total hemorrhagic necrosis". Currently, early opening of cellular tissue along the lower contour of the pancreas is not recommended, because. contributes to unnecessary trauma and opens the gate wider for the penetration of pathogenic intestinal flora into it.

From the modern standpoint, digital or instrumental revision of the omental sac prior to the development of inﬂated parapancreatic necrosis is not indicated and is recognized as erroneous.

Pathological changes in different parts of the pancreas may not coincide. Therefore, in order to establish the correct operational diagnosis, if it is extremely necessary, the head, body, and tail of this organ should be examined. The listed morphological phenomena are the source false assumptions about “total” or subtotal pancreatic necrosis, while in reality, under a layer of necrotic peritoneum and anterior subcapsular tissue, pancreatic damage 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 of intraoperative diagnostics.

3.2.3. Diagnostic errors in severe acute pancreatitis

An analysis of the case 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 cases their significance in the onset of death of the patient was very high. Elimination of only the most gross errors would reduce the lethality from this disease.

An analysis of the case 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 found that some forms of acute pancreatitis are quite typical of "clinical masks" of other forms of acute inflammatory diseases of the abdominal organs.

In this edition, devoted to 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 carried out by I.L. Rotkov (1988). In the materials of this author, the “clinical masks” of acute appendicitis were analyzed, which proceeded “under the flag” of other forms of ACCOPD, including acute pancreatitis. Similar comparisons in acute pancreatitis have not previously been made.

Reviewing the case histories of the dead in non-specialized surgical hospitals, we were convinced that some phases of development and forms of severe acute, as a rule, destructive pancreatitis are characterized by specific clinical "masks".

We analyzed the materials of the card index of lethal outcomes of severe acute pancreatitis that we created, in the study of which we identified 581 cases, the symptoms of which have a certain topographic and organ specificity, which is 64.6% of all studied lethal outcomes. Moreover, alternating sequences of various clinical images were often noted, which could rightly be called Theater of clinical masks of pancreatic necrosis... This is not an empty play on words, because. polymorphism of clinical manifestations of pancreatic necrosis is really fraught with diagnostic errors and, therefore, leads to an increase in the number of deaths.

Often, combinations of variants of "atypical" symptoms were also detected.

A medical error can pass without a trace for the patient, or it can lead to tragic consequences. But far from always the cause of the error is the incompetence of the doctor or his unwillingness to work. Sometimes things are much more difficult. Read more about the causes of medical errors in the article.
Recently, the topic of medical errors has been increasingly heard in the media. These words often hide the real crimes. For example, recently in one of the TV programs we were talking about a drunk doctor. But there is nothing to discuss here. This is a deliberately criminal act and is subject to criminal prosecution. It is better to talk about real medical errors that happened by chance.

Causes of medical errors

There are many reasons for medical errors. The most common of them is the wrong diagnosis. The second group includes errors in treatment tactics. They are closely related to the errors of the first group. Wrong diagnosis entails wrong treatment. The third group is organizational errors. The most striking example is the liquidation of the pediatric service promoted by the ex-Minister of Health of the Russian Federation Mikhail Zurabov and the widespread introduction of general practitioners. And, finally, the fourth group - 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. Limited and inaccurate medical knowledge is affected.

Recognizing the disease can be difficult, because it can proceed atypically, not at all as described in textbooks. In addition, it happens that the same disease in two patients manifests itself differently. 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, even the smallest mistake of a 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 mandatory participation of students. It does not matter who allowed them - a professor, associate professor, head of department or 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, incorrect hypotheses are possible in the diagnostic process (and making a diagnosis is the formulation of hypotheses that are either confirmed or rejected in the future), diagnostic errors are possible.

This chapter will analyze the definition and essence of the very concept of "medical errors", give their classification, consider the causes of medical, in particular diagnostic, errors, and show their significance in the course and outcome of diseases.

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

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) should be put in the first place. , III-IV degree burns of significant body surfaces, 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.

Delay in seeking medical help, self-treatment and treatment by healers, 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 in:

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

2. Illegal (criminally punishable) 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; serious consequences as a result of gross violations of the technique of diagnostic or therapeutic measures, non-compliance with instructions or instructions, for example, transfusion of blood of a different group due to violations of the instructions for determining the grouping of blood), when the doctor or paramedical worker had the necessary opportunities for the correct actions to prevent the development of complications and the consequences associated with them.

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

3. Medical errors.

4. Accidents in medical practice. No person, even in the most conscientious performance of his duties, in any profession and specialty, is free from erroneous actions and judgments.

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

“Smart is not the one who does not make mistakes. Such people do not exist and cannot exist. Clever is the one who makes mistakes that are not very significant and who knows how to easily and quickly correct them. (V. I. Lenin - Childhood disease of "leftism" in communism. Collected works, ed. 4, vol. 31, L., Politizdat, 1952, p. 19.)

But the mistakes of a doctor in his diagnostic and therapeutic work (and preventive work, if it concerns a sanitary doctor) differ significantly from the mistakes of a representative of any other specialty. Suppose an architect or builder made a mistake in designing or building a house. Their mistake, even if serious, can be calculated in rubles, and, in the end, the loss can be covered in one way or another. Another thing is the 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 is of concern not only to doctors themselves, but to all people, our entire community.

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

IV Davydovsky et al. in somewhat different words: "... a doctor's mistake in the performance of his professional duties, which are the result of a conscientious error and do not contain corpus delicti or signs of misconduct."

Therefore, the main content of this concept is an error (incorrectness in actions or judgments), as a result of a conscientious error. If we talk, for example, about diagnostic errors, this means that the doctor, having asked in detail and examined the patient 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 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 the responsibility 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 that take place 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 unambiguous; the course of these changes depends on many factors, both inside the body and outside it.

The diagnostic process can be compared with the solution of 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 features. his course of the disease. To this we can add that in some cases the doctor has little time (and sometimes not enough opportunities) to study 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 wrote: “Life is short, the path of art is long, opportunity is fleeting, judgment is difficult. People's needs force us to decide and act."

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

CHAPTER II

DIAGNOSTIC THINKING:

ABOUT PSYCHOLOGICAL CAUSES OF MEDICAL ERRORS

2.1. The concept of medical errors, their classification.

Objective and subjective causes of medical errors.

Above, the psychological foundations of communication between the doctor and the patient were considered, on which the success of the entire diagnostic work of the doctor largely depends.

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

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) should be put in the first place. , burns III– IV degrees of significant body surfaces, etc.), poisoning with various substances, including drugs, andalso various extreme conditions (mechanical asphyxia, exposure to extreme temperatures, electricity, high or low atmospheric pressure), etc.

Delay in seeking medical help, self-treatment and treatment by healers, 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 in:

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

3. Medical errors.

4. Accidents in medical practice. No person, even in the most conscientious performance of his duties, in any profession and specialty, is free from erroneous actions and judgments.

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

“Smart is not the one who does not make mistakes. Such people do not exist and cannot exist. Clever is the one who makes mistakes that are not very significant and who knows how to easily and quickly correct them. ”(V. I. Lenin – Children's disease of “leftism” in communism. Sobr. essays, ed. 4, vol. 31, L., Politizdat, 1952, p. 19.)

But the mistakes of a doctor in his diagnostic and therapeutic work (and preventive work, if it concerns a sanitary doctor) differ significantly from the mistakes of a representative of any other specialty. Suppose an architect or builder made a mistake in designing or building a house. Their mistake, even if serious, can be calculated in rubles, and, in the end, the loss can be covered in one way or another. Another thing– doctor's mistake. 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 is of concern not only to doctors themselves, but to all people, our entire community.

Currently, the following definition is generally accepted: 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 with co-authors (Davydovsky I. V. et al.Medical errors. Big medical encyclopedia. M., Sov. encyclopedia, 1976, v. 4, p. 442– 444.) give the same definition in essence, but in somewhat different words: "... a doctor's mistake in the performance of his professional duties, which are the result of a conscientious error and do not contain corpus delicti 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 that take place 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 unambiguous; the course of these changes depends on many factors, both inside the body and outside it.

The diagnostic process can be compared with the solution of a multifactorial mathematical problem, an equation with many unknowns, and there is no single algorithm for solving such a problem. The formation and justification 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 features. his course of the disease. To this we can add that in some cases the doctor has little time (and sometimes not enough opportunities) to study 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 wrote: “Life is short, the path of art is long, opportunity is fleeting, judgment is difficult. People's needs force us to decide and act."

What are the causes of medical errors?

These reasons can be divided into two groups:

1. Objective, that is, not dependent on the doctor himself and the degree of his professional training.

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

Of 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 injured person (in urgent cases requiring immediate attention and medical intervention), the lack of necessary diagnostic equipment and equipment, as well as an atypical course of the disease, the presence of two or even more diseases. I. V. Davydovsky said this well: “... medicine is not a technique dominated by exact sciences– physics, mathematics, cybernetics, which are not the foundations of the doctor's logical operations. These operations, as well as the study itself, are particularly 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 cause of medical errors and no guide, no experience is able to guarantee the absolute infallibility of the thoughts and actions of the doctor, although, as an ideal, this remains our motto.

It would be wrong to see in this statement of 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 mistakes and omissions made by doctors, an attempt to justify them with objective reasons. In his other works, I. V. Davydovsky analyzes and generalizes the causes of errors, which are the most frequent,- subjective.

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

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

2. Insufficiency of laboratory and X-ray studies, incorrect conclusions of radiologists and insufficient critical attitude of clinicians to these conclusions.

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

3. Incorrect organization of consultations, in particular in absentia, without the participation of the attending physician of consultations, underestimation or overestimation of the opinion of consultants.

4. Inadequate generalization and synthesis of the history data, symptoms of the disease and the results of the examination of the patient, the inability to use all these data in relation to the characteristics of the course of the disease in a particular patient, especially in its atypical course. To the subjective reasons for erroneous diagnosis, which are listed by S. S. Weil, one more should be added: failure to fulfill the minimum of mandatory studies, as well as other studies that could be carried out.

We have given only subjective reasons. Analyzing them, it is easy to see that in most of them we are talking not only about the wrong actions of the doctor, as a result of his insufficient qualifications, but also about the failure to perform the actions that are mandatory for the doctor. So, it is impossible to justify the lack of qualifications and little experience neglecting the anamnesis, disuse opportunities for consultation with experienced doctors, failure to conduct those laboratory or functional studies that could be done. In such cases, we can talk about the presence of elements of negligence in the actions of the doctor, and there will be no reason to assess 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 a 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 the doctor in the process of diagnosis, the degree of sensitivity of the doctor's analyzer systems, the features of the doctor's memory, the properties of his attention, switching, attention stability, etc.

From what has been said, it follows logically that the measure to prevent diagnostic errors should be the constant professional improvement of the 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, analyze them in order to avoid similar ones in his future work. An example in this respect was set by the great Russian surgeon II. I. Pirogov, who made his mistakes public, rightly believing that it is possible "...by truthful open recognition of one's mistakes and by revealing an intricate mechanism, one can save his students and novice doctors from repeating them."

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

Practice shows that diagnostic errors are made not only by young, but also by experienced doctors with high professional training and long work experience. But they are wrong in different ways. Young doctors make mistakes more often and in cases that are fairly simple in terms of diagnosis, 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, that is, cases that are difficult to diagnose, but boldly go towards them. For them, high-ranking representatives of medicine, the goal– save the sick– 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 the choice of method and treatment (they are usually divided into medical-technical and medical-tactical).

3. Errors in the organization of medical care. In addition to those listed, some authors also distinguish errors in the maintenance of medical records. If we talk about these errors, then in their occurrence, as well as in the occurrence of medical and technical errors, objective causes should be completely excluded. Here we can only talk about the shortcomings of the doctor's training, that is, the subjective cause of these errors.

Our task was to analyze diagnostic errors and their causes, since they are more common and, in most cases, determine the errors of a medical nature, although in some cases errors in treatment occur even with a correctly diagnosed diagnosis.

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

(Mistakes 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 - Mistakes and complications in heart and lung surgery, Minsk 1963, p. 212;

V. V. Kupriyanov, N. V. Voskresensky– Anatomical variants and errors in the practice of a doctor, 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 - Mistakes and dangers in childhood surgery, M., 1979, p. 183; Diagnostic and therapeutic errors of the doctor. Sat. scientific works, Gorky, 1985, p. 140.)

What is the responsibility for medical errors?

It has already been noted above that in cases of medical errors, in which no elements of negligence or medical ignorance are seen, the question of the doctor's legal (administrative or criminal) responsibility is not raised. However, in all cases there is a moral responsibility. A real humanist doctor with a heightened sense of duty cannot but think about the mistake he made and its consequences, cannot help but worry, and for every mistake his conscience passes judgment on him, and this judgment of conscience can be heavier than a human judgment.

Each mistake should be analyzed in the medical team. It is necessary to establish the causes and conditions for the occurrence of an error in each specific case. When parsing 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 mistakes? In medical institutions, this is done at meetings of medical control commissions and clinical and anatomical conferences with the participation of pathologists or forensic experts. Such conferences are a good school not only for teaching, but also for educating doctors and other medical workers.

The outstanding Soviet clinician and scientist I. A. Kassirsky in the monograph "On Healing", which must be carefully studied by every doctor, wrote: "Mistakes - the inevitable and sad costs of medical activity, mistakes are always bad, and the only optimal thing that follows from the tragedy of medical errors is that they teach and help to ensure that they do not exist ... they carry in their essence 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- "About medicine" - M., Medicine, 1970, p. 27.)

Accidents in medical practice.

Only a person guilty of committing a crime, that is, a person who intentionally or negligently committed a socially dangerous act prescribed 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 foresee and could not foresee these socially dangerous consequences.

Here we can talk about a case, i.e., an event that is not caused by someone's intent or negligence, and therefore there is neither intentional nor careless guilt in the actions (inaction) of this or that 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 the data of 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 causes that cause them are rare. So, accidents include severe allergies, up to the death of the patient, due to intolerance to the drug (usually antibiotics) at the first contact of the patient with him; the so-called "anesthetized death" with shown and perfectly correctly performed anesthesia. The causes of "anesthetized death" are far from always established, even with pathoanatomical study of the corpse. In such cases, the causes of adverse outcomes lie in the features of the functional state of the patient, which could not be taken into account even with the most conscientious actions of the doctor.

If an unfavorable outcome of a diagnostic or therapeutic intervention was caused by insufficient, negligent 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: