Medical mistakes - Medical mistake. Definition and classification of medical errors

Last year, about 200 forensic medical examinations were carried out on medical cases in Belarus. Most often, the basis for them was claims and accusations against doctors.

Statistics, albeit partial, argue that harm to life and health as a result of a medical error is a fairly common phenomenon. But, neither in Belarus, nor among our neighbors, no one will tell you exactly how many people became disabled or died as a result of the wrong actions of doctors. But, for example, the United States knows about its medical tragedies: every year, from 44,000 to 98,000 people die in the hospitals of this country due to medical errors, the Respublika newspaper writes.
But is everything as simple as it seems from the outside?

Plugs, plugs and life

Patient L. underwent a planned endoscopy in one of the clinics in Bobruisk. The endoscope tube did not pass further than the middle third of the esophagus due to some obstruction that the doctor could not see. He tried to overcome it blindly, by force, but he did not succeed. The doctor interrupted the study and sent the patient on his own to the oncology dispensary.

The woman came there five hours after the endoscopy. Dispensary specialists diagnosed damage to the inflammatory esophagus, trachea and inflammation of the mediastinal organs. Despite urgent treatment and hospitalization, the patient died.

Later, the forensic medical report will indicate a gross medical error of the endoscopist: he did not examine the patient before the study, during endoscopy he did not carefully empty the esophagus, and so on.

Patient L. turned to an ENT doctor in one of the polyclinics in Minsk with complaints of sore throat when swallowing, saying that "a fish bone got into his throat while eating the day before." The doctor examined the patient, but did not find a foreign body and let the patient go home.

After that, the man went to different hospitals, he was given different diagnoses, and his death on the 20th day after the first treatment was provoked by the same undetected fish bone. The forensic examination noted that at all stages, in violation of the protocols, the patient was not examined the esophagus, they did not diagnose a foreign body there, which as a result led to the tragedy.

The details of these and many other stories became known thanks to the work of forensic expert commissions. These examples are gross defects in the quality of medical care. Maybe I would like to console and say that such cases are quite rare, but it would not be true. Because from 2002 to 2010, during 822 forensic medical examinations, 996 such gross defects were recorded.

The sad arithmetic is as follows: for eight years, 353 times doctors incorrectly or inaccurately diagnosed, 247 times grossly violated clinical protocols for diagnosis and treatment, 59 times tactically and technically incorrectly performed complex studies and surgical interventions. Obstetric disorders were detected in 31 cases, and 7 times surgeons left foreign bodies in the body cavities of patients.

Over the years, employees of our service have performed 1,298 forensic medical examinations, - says Yuri Gusakov, chief state forensic expert of the Republic of Belarus. - And each time the claims and accusations against doctors became the basis for them. According to the materials of criminal cases, examinations were carried out 174 times. In general, over the past decade from year to year there has been a steady increase in the number of examinations in the so-called medical cases: from 68 in 2000 to 199 in the past.

Employees of the State Service for Medical Forensic Examinations of the Republic of Belarus can come on their own with a check to a medical institution where something strange is happening, after informing the Ministry of Health. And every time there are good reasons for that. Sometimes surprising facts come up.

The cardiology department of one of the hospitals in the Minsk region, by the way, is well equipped, - Yury Gusakov recalls. - There, one after another, urgently delivered people with heart fibrillation began to die. A well-known device called a defibrillator successfully removes a person from this state. One person died, the second... "Got a defibrillator?" - we ask. "Yes," they say. And indeed there are some new excellent defibrillators. "When bought?" - "Two years ago". - "Why don't you use it?" "Their plug doesn't fit our sockets." The fork costs three rubles, and millions have been invested in the hospital.

Guilty. In frivolity

The fate of doctors, heads of medical institutions, in whose work a defect is discovered, can develop in different ways. And they can be held responsible for different things: from disciplinary measures to administrative penalties and criminal punishment. Although, as noted by Aleksey Kralko, a specialist in medicine and law, a teacher at the Belarusian Medical Academy of Postgraduate Education, there are much fewer criminal cases for medical errors than civil cases.

If we analyze the review of judicial practice, then there are enough claims from patients, but in most cases they end in favor of the defendant. Why? Imperfection of the mechanisms of work in the medical legal field. After all, even the term "medical error" itself is quite contradictory.

At one time, Academician Davydovsky called the conscientious delusion of a doctor, which is based on the imperfection of the medical science itself and its methods, the non-standard course of the disease, or the insufficient preparation of the doctor. But on one condition: if this does not reveal elements of dishonesty, negligence, frivolity. That is, a medical error is, by and large, the innocent actions of a doctor. But intentionally causing harm is not a mistake, it becomes a crime. That is why the term "medical error" is not used in practice by jurisprudence - it is not even defined by regulatory documents. This concept is more appropriate among the physicians themselves to reflect the objective infidelity of the actions of colleagues.

From a legal point of view, the so-called medical error has all the signs of an offense and can always be seen as careless guilt in the form of frivolity or negligence. In this case, an unfavorable outcome of treatment occurs for subjective reasons. And the same result, but due to objective reasons, lawyers refer to accidents that do not depend on the will of the doctor.

For example, a person was hospitalized too late in a serious condition, or he has a rare disease, or a disease with unexpressed symptoms, or there is no possibility of conducting special studies in the hospital, or, in general, there is little information in medical science about the essence and mechanism of the pathological process. But to be honest, most of the offenses in medicine are committed through negligence.

An unfavorable outcome of treatment associated with a conscientious delusion of a doctor is usually referred to as medical errors. The term "medical error" is used only in medical practice.

The variety of medical errors, their causes and conditions of occurrence has led to the fact that until now there is no single concept of medical error, which naturally makes it difficult to medical and legal assessment of the erroneous actions of medical workers. The main criterion for medical error is the conscientious error of a doctor arising from certain objective conditions without elements of negligence, negligence and professional ignorance.

Medical errors are divided into three groups:

1) diagnostic errors - non-recognition or erroneous recognition of the disease;

2) tactical errors - incorrect definition of indications for surgery, erroneous choice of the time of the operation, its volume, etc.;

3) technical errors - incorrect use of medical equipment, use of inappropriate medical and diagnostic tools, etc.

Medical errors are due to both objective and subjective reasons.

Objective difficulties in diagnosing a number of diseases arise due to the latent atypical course of the disease, which can often be combined with other ailments or manifest itself in the form of other diseases, and sometimes difficulties in diagnosing diseases and injuries are associated with the state of alcohol intoxication of the patient.

Timely diagnosis of pneumonia in children aged 1-3 years also causes great difficulties, especially against the background of catarrh of the upper respiratory tract.

Example.

Klava B., aged 1 year 3 months, died during her daytime sleep in a nursery on January 29, 1998. From January 5 to 17, she suffered from an acute respiratory infection, for which she did not attend the nursery. The nursery doctor admitted the child on January 18 with residual effects after suffering catarrh of the upper respiratory tract (abundant mucous discharge from the nose, single dry rales were heard in the lungs), subsequently the child was examined by a doctor only on January 26. The diagnosis of pneumonia was not established, but it was noted that the symptoms of catarrh of the upper respiratory tract persist, but the child's temperature was normal. The treatment continued in the manger (potion - for coughing, drops in the nose - for the common cold). The child looked unwell, was lethargic, drowsy, ate without appetite, coughed.

On January 29, 1998 at 1 pm Klava B., together with other children, was put to bed in the bedroom. The child slept peacefully, did not cry. When the children were raised at 3 p.m., Klava B. showed no signs of life, but was still warm. The older nurse nurse immediately began to give her artificial respiration, gave her two injections of caffeine, the child's body was warmed by heating pads. Arriving ambulance doctor performed mouth-to-mouth artificial respiration and chest compressions. However, it was not possible to revive the child.

During the forensic medical examination of the corpse of Klava B., the following were found: catarrhal bronchitis, widespread serous-catarrhal pneumonia, interstitial pneumonia, multiple foci of hemorrhages in the lung tissue, which caused the death of the child.

According to the expert commission, the mistake of the doctors' actions in this case was that the child was discharged to the nursery not recovered, with residual symptoms of a respiratory infection. The nursery doctor had to ensure active monitoring of the child, conduct additional studies (radioscopy, blood tests). This would make it possible to more correctly assess the condition of a sick child and actively carry out therapeutic measures. It would be more correct to treat a child not in the conditions of a healthy group of children in a nursery, but in a medical institution.

Answering the questions of the investigating authorities, the expert commission pointed out that the defects in the management of a sick child were largely due to the difficulty in diagnosing interstitial pneumonia, which proceeded with an undisturbed general condition of the child and normal body temperature. Pneumonia could develop in the last days of the child's life. The death of children with pneumonia can also occur in a dream without any pronounced signs of the disease.

Practice shows that the majority of medical errors are associated with an insufficient level of knowledge and little experience of the doctor. At the same time, errors, such as diagnostic ones, are encountered not only by beginners, but also by experienced doctors.

Less often, errors are due to the imperfection of the applied research methods, the lack of the necessary equipment or technical shortcomings in the process of its use.

Example.

Patient P., aged 59, was admitted to the hospital on February 10, 1998 № 131 with a diagnosis of hypochromic anemia. During clinical examination, a hernia of the esophageal opening of the diaphragm was established, and a niche in the lower esophagus was detected radiographically.

To clarify the nature of the niche and exclude a malignant neoplasm, for medical reasons, the patient underwent esophagoscopy on February 12, 1998, during which it was found that the mucous membrane of the esophagus was so thickened that the tube could not even be passed into the upper third of the esophagus. Due to the ambiguity of the esophagoscopy picture, repeated X-ray examination and esophagoscopy under anesthesia were recommended.

The next day, the patient's condition P. deteriorated sharply, the temperature rose to 38.3°C, pain appeared when swallowing. An x-ray examination on February 15 revealed a defect in the left wall of the esophagus and a blackout in the region of the upper mediastinum. Diagnosis: rupture of the esophagus, mediastinitis. On the same day, an urgent operation was performed - opening the paraesophageal tissue on the left, emptying the abscess, draining the mediastinum. The postoperative course was difficult, against the background of anemia.

On March 2, 1998, patient P. suddenly developed massive bleeding from a wound on his neck, from which he died 10 minutes later.

During the forensic medical examination of P.'s corpse, it was established: instrumental rupture of the anterior and posterior walls of the cervical esophagus, purulent mediastinitis and encysted left-sided pleurisy; condition after surgery - drainage of an abscess of the paraesophageal tissue on the left; slight erosion of the left common carotid artery; a large number of dark red blood clots in the cavity of the drainage channel, anemia of the skin, myocardium, liver, kidneys, moderate atherosclerosis of the aorta and coronary arteries of the heart, disseminated small-focal cardiosclerosis, reticular pneumosclerosis and emphysema.

In this case, a technical error in the process of esophagoscopy led to a serious illness, which was complicated by fatal bleeding.

The modern form of medical errors are iatrogenic diseases, usually arising from a careless word or incorrect behavior of a doctor or nursing staff. The incorrect behavior of a medical worker can have a strong adverse effect on the patient's psyche, as a result of which he develops a number of new painful sensations and manifestations that can even turn into an independent form of the disease.

The vast majority of iatrogenic diseases depend not so much on the inexperience and ignorance of the doctor, but on his inattention, tactlessness, lack of a sufficient general culture. For some reason, such a doctor forgets that he is dealing not only with a disease, but also with a thinking, feeling and suffering sick person.

More often, iatrogenic diseases develop in two forms: the course of the patient's organic disease worsens significantly or psychogenic, functional neurotic reactions appear. In order to avoid iatrogenic diseases, information to the patient about the disease should be given in a clear, simple and non-intimidating form.

To prevent any erroneous actions of the doctor, each case of medical error must be carefully studied and discussed at medical conferences.

When evaluating medical errors with the help of forensic medical expert commissions, it is necessary to reveal the essence and nature of the doctor’s wrong actions and, as a result, get a basis for qualifying these actions as conscientious and, therefore, permissible, or, conversely, unfair and unacceptable. Objective difficulties in identifying certain diseases arise as a result of the peculiarities of the pathological process itself. The disease can proceed latently or take an atypical course, be combined with other diseases, which, of course, cannot but affect the diagnosis. For example, a strong degree of alcohol intoxication of persons who have received skull injuries makes it difficult for neurological examination and recognition of a traumatic brain injury. Misdiagnosis is sometimes caused by the behavior of patients who can actively oppose research, refuse biopsies, hospitalization, etc.

Accidents in medical practice

Sometimes the unfavorable outcome of an operation or other medical intervention is accidental, and the doctor was not able to foresee the misfortune. Such outcomes in the medical literature are called accidents in medical practice. Until now, there is no single concept of "accident". Some doctors and lawyers try to misinterpret this term in an unjustified way, including, in non-accidental cases, careless actions of medical workers, medical errors, and even individual cases of negligent attitude of medical personnel to their duties.

Accidents include all deaths that were unexpected for the doctor. Examples of such outcomes include: 1) activation of a chronic infection after surgery; 2) postoperative complications - cases of peritonitis and bleeding after simple appendectomies, rupture of the surgical scar or thrombosis many days after the operation, air embolism of the heart, and many others; 3) suffocation with vomit during anesthesia; 4) death after encephalography, esophagoscopy, etc.

Professor A.P. Gromov proposes to understand an accident in medical practice as an unfavorable outcome of a medical intervention associated with random circumstances that a doctor cannot foresee and prevent. To prove an accident in medical practice, it is necessary to completely exclude the possibility of professional ignorance, negligence, negligence, as well as medical error. Such outcomes are sometimes associated with intolerance and allergy to certain medicinal preparations, which was not known during the life of the patient. To date, the literature has accumulated significant material on the side effects of various drugs, including allergic and toxic reactions after parenteral administration of antibiotics. One of the measures to prevent adverse outcomes from anaphylactic shock with the introduction of antibiotics is a preliminary determination of the sensitivity of patients to them.

Random adverse outcomes can be observed when examining patients at the time of various diagnostic manipulations. Forensic practice shows that such outcomes are sometimes observed during diagnostic angiography using iodine preparations.

Sometimes accidental deaths are observed during transfusion of blood corresponding to the blood group of patients, or during transfusion of blood substitutes.

Accidental death during surgical interventions is the most difficult to recognize, since it is not always possible to fully understand the causes and mechanism of its onset.

Thus, only such unsuccessful outcomes can be attributed to accidents in medical practice, in which it is impossible to foresee the consequences of medical actions, when treatment failures do not depend on medical errors and other omissions, but are associated with an atypical course of the disease. , individual characteristics of the organism, and sometimes with the lack of elementary conditions for the provision of emergency medical care.

Lawyers should be aware that all this must be taken into account by forensic expert commissions when assessing lethal outcomes in medical practice. Before coming to the conclusion about the occurrence of a fatal outcome as a result of an accident or linking it to the negligent actions of a doctor, such commissions must study in detail all the circumstances related to this incident.

Forensic Medicine: Proc. allowance for universities
Ed. prof. A.F. Volynsky

normal function of the gland (euthyroidism, when, with an increase in the volume of the thyroid gland, the hormones secreted by it are within normal values). This condition is associated with iodine deficiency, the intake of certain substances and drugs, as well as hereditary conditions and certain types of cancer. Such a change is usually not accompanied by any symptoms, but with a large volume of the gland, discomfort may appear in the neck, especially when wearing clothes with a collar, the thyroid gland becomes visible to the eye;

hyperfunction (when an increase in the thyroid gland is accompanied by excessive synthesis of hormones). This condition is called thyrotoxicosis. There are also several reasons for it, the most common is diffuse toxic goiter (or Graves' disease). Thyrotoxicosis has a rather vivid picture: a person loses weight, palpitations appear, trembling in the hands, sweating, irritability, tearfulness, poor sleep, hair loss. In women, the menstrual cycle is often disturbed, and in men, potency decreases. The patient is often diagnosed with various diagnoses, for which he is unsuccessfully treated. The correct diagnosis is often established with a delay, when there are severe lesions of the cardiovascular system.

hypofunction (reduced synthesis of hormones) - hypothyroidism. The reasons may be autoimmune processes, taking certain drugs, thyroid surgery, radioactive iodine treatment. Symptoms of hypothyroidism are nonspecific: weakness, fatigue, dry skin, sometimes swelling of the face, legs, chilliness, constipation, etc. Such manifestations can also be found in an absolutely healthy person. The treatment is very simple and not burdensome for the patient, but if left untreated, hypothyroidism can lead to serious consequences.

Nodular (or multinodular) goiter is established when there is a node (nodes) in the thyroid gland - neoplasms of a rounded shape of various sizes. Like diffuse enlargement of the thyroid gland, nodular goiter may be accompanied by normal, hyper- or hypo-thyroidism. If the nodule is accompanied by normal thyroid function, it does not cause discomfort to the patient until it increases in size and is visible on the neck. It must be remembered that any thyroid nodule is an indication for the exclusion of a malignant process, even if the nodule is small. Of particular concern are nodes in men, young people, people who lived in areas of radioactive contamination, as well as those who have relatives with certain types of cancer. If nodular goiter is accompanied by hyper- or hypofunction of the thyroid gland, the symptoms will be the same as described above.

The thyroid gland during pregnancy has features in its functioning, while laboratory standards for hormones also change. Sometimes a woman who has not previously had changes in the thyroid gland during pregnancy does not have enough of her hormones to meet the needs of herself and the developing child. Such a decrease in hormones can affect the mental development of the baby. Therefore, women are advised to examine the function of the thyroid gland during pregnancy and at the planning stage. If a woman had a thyroid disease before pregnancy, then when it occurs, a dose adjustment of the drugs taken is required.

Diagnosis of diseases of the thyroid gland is currently not particularly difficult. Not only various laboratory research methods are available (determination of hormones, markers of some types of thyroid cancer, genetic research, etc.), but also modern instrumental research methods (ultrasound, scanning, needle biopsy, etc.).

Treatment of thyroid diseases should be based on an individual approach to each patient. What is normal for one person may be abnormal for another and vice versa. It must be remembered that modern technologies make it possible to successfully treat not only hypo- and hyperfunction of the thyroid gland with diffuse or nodular goiter, but even thyroid cancer, as well as prevent the development of certain types of cancer in its family forms.

medical errors

An unfavorable outcome of treatment associated with a conscientious delusion of a doctor is usually referred to as medical errors. The term "medical error" is used only in medical practice.

The variety of medical errors, their causes and conditions of occurrence has led to the fact that so far there is no single concept of medical error, which naturally makes it difficult for medical and legal assessment of the erroneous actions of medical workers. The main criterion for medical error is the conscientious error of a doctor arising from certain objective conditions without elements of negligence, negligence and professional ignorance.

Medical errors are divided into three groups:

1) diagnostic errors - non-recognition or erroneous recognition of a disease;

2) tactical errors - incorrect definition of indications for surgery, erroneous choice of the time of the operation, its volume, etc.;

3) technical errors - incorrect use of medical equipment, use of inappropriate medicines and diagnostic tools, etc.

Medical errors are due to both objective and subjective reasons.

Great difficulties are also caused by the timely diagnosis of pneumonia in children aged 1-3 years, especially against the background of catarrh of the upper respiratory tract.

Example.

Klava B., aged 1 year 3 months, died during her daytime sleep in a nursery on January 29, 1998. From January 5 to 17, she suffered from an acute respiratory infection, for which she did not attend the nursery. The nursery doctor admitted the child on January 18 with residual effects after suffering catarrh of the upper respiratory tract (abundant mucous discharge from the nose, single dry rales in the lungs were heard), later the child was examined by a doctor only on January 26. The diagnosis of pneumonia was not established, but it was noted that the symptoms of catarrh of the upper respiratory tract persist, but the child's temperature was normal. The treatment continued in the manger (potion - for coughing, drops in the nose - for the common cold). The child looked unwell, was lethargic, drowsy, ate without appetite, coughed.

On January 29, 1998, at 1 pm Klava B., together with other children, was put to bed in the bedroom. The child slept peacefully, did not cry. When the children were raised at 3 pm, Klava B. showed no signs of life, but was still warm. The older nurse of the nursery immediately began to give her artificial respiration, gave her two injections of caffeine, the child's body was warmed by heating pads. Arriving ambulance doctor performed mouth-to-mouth artificial respiration and chest compressions. However, the child could not be revived.

According to the expert commission, the mistake of the doctors' actions in this case was that the child was discharged to the nursery not recovered, with residual symptoms of a respiratory infection. The nursery doctor had to ensure active monitoring of the child, conduct additional studies (radioscopy, blood tests). This would make it possible to more correctly assess the condition of a sick child and more actively carry out therapeutic measures. It would be more correct to treat a child not in the conditions of a healthy group of children in a nursery, but in a medical institution.

Practice shows that the majority of medical errors are associated with an insufficient level of knowledge and little experience of the doctor. At the same time, errors, such as diagnostic ones, occur not only among beginners, but also among experienced doctors.

Less often, errors are due to the imperfection of the applied research methods, the lack of the necessary equipment or technical shortcomings in the process of its use.

Example.

The next day, the condition of the patient P. deteriorated sharply, the temperature rose to 38.3°C, pain appeared when swallowing. An x-ray examination on February 15 revealed a defect in the left wall of the esophagus and a blackout in the region of the upper mediastinum. Diagnosis: rupture of the esophagus, mediastinitis. On the same day, an urgent operation was performed - opening the paraesophageal tissue on the left, emptying the abscess, draining the mediastinum. The postoperative course was difficult, against the background of anemia.

On March 2, 1998, patient P. suddenly developed massive bleeding from a wound on his neck, from which he died 10 minutes later.

In this case, a technical error in the process of esophagoscopy led to a serious illness, complicated by fatal bleeding.

The modern form of medical errors are iatrogenic diseases, usually arising from a careless word or incorrect behavior of a doctor or nursing staff. Incorrect behavior of a medical worker can have a strong adverse effect on the patient's psyche, as a result of which he develops a number of new painful sensations and manifestations that can even turn into an independent form of the disease.

More often, iatrogenic diseases develop in two forms: the course of the patient's organic disease worsens significantly or psychogenic, functional neurotic reactions appear. In order to avoid iatrogenic diseases, information to the patient about the disease must be given in a clear, simple and non-intimidating form.

To prevent any erroneous actions of a doctor, each case of medical error must be carefully studied and discussed at medical conferences.

When evaluating medical errors with the help of forensic medical expert commissions, it is necessary to reveal the essence and nature of the doctor’s wrong actions and, as a result, get a basis for qualifying these actions as conscientious and, therefore, permissible, or, conversely, unfair and unacceptable. Objective difficulties in identifying certain diseases arise as a result of the characteristics of the pathological process itself. The disease can be latent or take an atypical course, be combined with other diseases, which, of course, cannot but affect the diagnosis. For example, a strong degree of alcohol intoxication of persons who have received skull injuries makes it difficult to perform a neurological examination and recognize a traumatic brain injury. Misdiagnosis is sometimes due to the behavior of patients who may actively oppose research, refuse biopsies, hospitalization, etc.

Accidents in medical practice

Sometimes the unfavorable outcome of an operation or other medical intervention is accidental, and the doctor was not able to foresee the misfortune. Such outcomes in the medical literature are called accidents in medical practice. Until now, there is no single concept of "accident". Some doctors and lawyers try to misinterpret the term broadly, including in accidents careless actions of medical workers, medical errors, and even individual cases of negligent attitude of medical personnel to their duties.

Professor A.P. Gromov proposes to understand an accident in medical practice as an unfavorable outcome of medical intervention associated with random circumstances that a doctor cannot foresee and prevent. To prove an accident in medical practice, it is necessary to completely exclude the possibility of professional ignorance, negligence, negligence, as well as medical error. Such outcomes are sometimes associated with intolerance and allergy to certain medicinal preparations, which was not known during the life of the patient. To date, the literature has accumulated significant material on the side effects of various drugs, including allergic and toxic reactions after parenteral administration of antibiotics. One of the measures to prevent adverse outcomes from anaphylactic shock with the introduction of antibiotics is the preliminary determination of the sensitivity of patients to them.

Sometimes accidental deaths are observed when transfusing blood that matches the blood type of patients, or when transfusing blood substitutes.

Accidental death during surgical interventions is the most difficult to recognize, since it is not always possible to fully elucidate the causes and mechanism of its onset.

Thus, only such unsuccessful outcomes can be attributed to accidents in medical practice, in which it is impossible to foresee the consequences of medical actions, when failures in treatment do not depend on medical errors and other omissions, but are associated with an atypical course of the disease, individual characteristics of the body, and sometimes with the lack of elementary conditions for the provision of emergency medical care.

Lawyers should be aware that all this must be taken into account by forensic medical expert commissions when assessing lethal outcomes in medical practice. Before coming to the conclusion about the occurrence of a fatal outcome as a result of an accident or linking it to the negligent actions of a doctor, such commissions must study in detail all the circumstances related to this incident.

Navigation

« »

Sectional room. Another ordinary opening. In front of me is a middle-aged man. Clinicians made an intravital diagnosis of thrombosis of the mesenteric vessels and intestinal necrosis. But revision of the abdominal cavity showed the presence of hemorrhagic pancreatic necrosis. And now, it would seem that an “ordinary” autopsy has become a good example of iatrogenesis in surgical practice. And there are many such examples for the work of a pathologist.

Our expert:

Oleg Inozemtsev

pathologist, experience in the specialty - 15 years. Part-time endoscopist and radiation diagnostician. The place of work is a multidisciplinary hospital.

When the doctors are powerless and the patient dies, I begin my work as a pathologist. First at the dissecting table, then in the histological laboratory. In addition to establishing the exact cause of the patient's death, it is important for me to find out if there is a discrepancy between the clinical and pathoanatomical diagnoses. If there is a discrepancy, every time I feel disappointed in the imperfection of medical science, in the illiteracy of my colleagues, and I think about their responsibility. Based on my own observations, I compiled my personal top of the most common medical errors leading to the death of a patient, and gave illustration stories. Let's go from most frequent to least frequent.

1. Lightning situations

An example from personal experience: a young man of 20 years old fell ill with ARVI, which began with chills, fever, cough, runny nose. Symptomatic treatment was started. But four days later the patient's condition deteriorated sharply, the diagnosis was pneumonia. The disease proceeded rapidly, and a day later the patient exited. Pathological anatomical autopsy confirmed the presence of pneumonia. Why did such a disease as banal pneumonia, which most often ends happily, lead to a terrible ending?! The cause of iatrogeny lies in the late diagnosis of the disease and its fulminant course.

The term "iatrogenic" was first proposed by the German psychiatrist Oswald Bumke in 1925. By this term, he proposed to designate psychogenic diseases arising as a result of a careless medical statement (from the Greek: iatros - doctor, genes - generative, i.e. "a disease generated by a doctor"). According to ICD-10, iatrogenic is understood as any adverse or undesirable consequences of medical procedures (preventive, diagnostic and therapeutic interventions). This should also include complications of medical procedures that were the result of the actions of a medical worker, regardless of whether they were erroneous or correct.

On a note: The mere possibility of a fulminant course of diseases makes it necessary to start treatment as early as possible and with appropriate doses of effective drugs.

2. Invasive techniques

A patient with suspected peptic ulcer of the stomach and duodenum was referred for fibrogastroduodenoscopy. During the procedure, perforation of the posterior pharyngeal wall occurred. The defect was not immediately detected, neck phlegmon with deep intoxication developed, the patient died. Another example: a patient has diverticulosis of the descending and sigmoid colon. A colonoscopy was scheduled. During its implementation, there was a rupture of the large intestine in the region of the rectosigmoid angle with profuse bleeding, and the death of the patient from blood loss.

On a note: It is worth referring patients to invasive diagnostic methods only for strict indications, and endoscopic interventions and medical procedures should be carried out with extreme caution under the control of video endoscopic equipment.

3. Diseases from the "medicine"

A 55-year-old man has been suffering from metabolic arthritis for a long time. Acutely ill after taking a combined NSAID. Immediately there was a rash on the skin, changes in blood tests (increased ESR and leukocytosis). Later there was severe shortness of breath, pain in the chest, lumbar region. Treatment did not give positive results. The condition progressively worsened, and soon the patient died. At autopsy, no macroscopic changes were found. However, a histological examination of the internal organs revealed serous-productive inflammation with a predominance of lymphocytic and macrophage infiltrates, proliferative-membrano glomerulonephritis, endocarditis, interstitial pneumonia and hepatitis.

Intolerance or hypersensitivity to certain drugs and procedures (radiotherapy, radiotherapy, anesthesia) is common. Drug intolerance reaches 10-20%, and 0.5-5% of patients require treatment for drug complications. Timely cancellation of drugs allows you to avoid unforeseen severe complications, such as anaphylactic shock or acute hemolysis. But if the doctor does not associate the severity of the patient's condition with the use of the drug and does not cancel it, then a fatal outcome is not ruled out.

On a note: When prescribing any drug, you need to remember that an undesirable reaction may develop. From personal experience, serious ulcerations of the gastric mucosa and fatal bleeding are recalled when taking NSAIDs. Cytostatics, glucocorticoids, tetracycline, caffeine, reserpine, etc. also have an ulcerogenic property.

You should especially beware of allergic reactions when taking antibiotics, sulfanilamide drugs, non-narcotic analgesics, local anesthetics, antiepileptic drugs, iodine, arsenic, and mercury preparations. The consequences do not depend on the dose: even one tablet can lead to serious complications.

4. "Disguise"

There are cases that require a distinction between the concepts of medical error and medical misconduct. I'll give you an example. A patient is admitted with complaints of abdominal pain, nausea, and vomiting. The attending physician, and later the council, concluded: the patient has an exacerbation of chronic cholecystopancreatitis. Appropriate treatment was prescribed, but it did not give positive results. The patient's condition worsened and he soon died. An autopsy revealed acute myocardial infarction. Obviously, there was an abdominal form of a heart attack without typical retrosternal pain. What to do in this case: bring the doctor to criminal responsibility? Medical malpractice or medical error? In this case, of course, we are talking about a medical error, since the disease had an atypical course.

On a note: Clinicians should always be aware that many diseases have similar symptoms and "mask" to mislead the clinician. Therefore, we never forget about differential diagnosis: by comparing several diseases with similar symptoms, we will come to the correct diagnosis.

5. Atypical history

In surgery, it sometimes happens that a correctly performed surgical intervention leads to death. Example? It was described in 1983 in Natan Vladimirovich Elshtein's book Dialogue on Medicine. The patient had her tonsils removed. The operation is simple, performed frequently and usually has no consequences. But this patient started bleeding from the surgical wound. The fact is that the patient had an atypical location of the blood vessel, and this vessel was damaged during the intervention. Fortunately, the bleeding was stopped in time. But how could the surgeon foresee the presence of this anomaly?! This is a typical case of surgical iatrogenesis, which is difficult to predict. And it is very difficult in this case to explain to the relatives of the patient why and how a simple operation could lead to a tragic outcome.

Note: Surgeons should not forget that the human body is not perfect, organs and vessels may have an atypical location. It is sometimes possible to suspect and be prepared for "surprises" by external anomalies (stigmas). For example, during any surgical intervention in a patient with Morfan's syndrome with obvious external stigmas, a dissecting aortic aneurysm, which occurs in this syndrome, may rupture. In case of any doubts, it is better to play it safe by doing additional studies (angiography, ultrasound, etc.).

6. Scary thing - statistics

A 35-year-old patient was admitted to the hematology department of the hospital with enlarged lymph nodes in several areas of the body, enlarged liver and spleen. Cough and shortness of breath were also present. Anemia was revealed in the CBC, and an x-ray examination in the lung tissue revealed a 4×5 cm dark area and a hemorrhagic effusion (punctate) in the pleural cavities. A swab was taken from enlarged lymph nodes, in which Berezovsky-Sternberg cells and reticular cells were found. Based on these data, a diagnosis was made: Hodgkin's disease. Treatment has been given. Soon the patient died. An autopsy revealed bronchial cancer with metastases to the lymph nodes and liver. Clinical and post-mortem diagnoses did not match due to incorrect diagnosis and treatment.

This curious case of iatrogenic "from the word", which ended in the death of the patient, occurred in my practice. The woman had chronic ischemic heart disease. This, of course, disturbed her both physically and psychologically. And in order to somehow reassure his patient, the attending physician “cheered up” the patient, telling her that everything would be fine, and that she would not die before him. A fatal accident led to the fact that the attending doctor died the next day from an intracerebral hemorrhage. And the patient, having learned about his death, died a few days later from a myocardial infarction.

What was the error in the diagnosis? Doctors know that lung cancer is rare in young women, about 5-6 times less common than in men. This fact "weeded out" the hypothesis of lung cancer. Then a sharp and widespread enlargement of the lymph nodes aroused the suspicion of Hodgkin's disease. Also, clinicians misinterpreted the hemorrhagic nature of the effusion, which was indicative of lung cancer, and misinterpreted lymph node cytology data. It was necessary to take a biopsy from the lymph node for histological diagnosis, which was not carried out. In this case, the correct diagnosis would hardly have been able to contribute to recovery, but the fact of iatrogenesis is present.

On a note: The propaedeutics teacher used to tell us medical students, "If you think about statistics, you will never get a correct diagnosis." He was damn right. In addition, if a diagnostic standard has been developed for a certain condition, follow it.

For a common cause

The business of pathologists is not to convict the attending physician of the mistakes made, not to defeat him morally (sometimes financially), but to help the doctor learn from the mistakes made. Every time I conduct a debriefing and also invite doctors to autopsies, I hope that these difficult "training" events will delay the next case of iatrogenic death.