Public and media trials of medical errors & negligence need to be replaced by well-designed morbidity & mortality review system keeping in view international medical laws and policies.
Where does a death of a patient in a medical facility (expected or unexpected; following full medical support or because of alleged medical error or negligence) fall in healthcare practice? In modern healthcare practice, this is classified under the subject of “Morbidity & Mortality” commonly nicknamed by physicians as “M & M”.
Morbidity & Mortality (M&M).
Morbidity means the occurrence of a complication, disease, or unexpected response in the index patient during the institution of medical treatment or a procedure or operation by a medical practitioner. Examples are innumerable namely allergic reaction to an administered drug, bleeding during or after a surgical procedure, infection following an operation, nerve injury due to a drug administered at the wrong site, etc.
Mortality means the fatal outcome (death) of an index patient during the institution of medical treatment or a procedure or operation by a medical practitioner. All deaths occurring in a hospital setting following the institution of medical treatment should be explored carefully and death caused by basic disease or due to medical treatment should be separated.
“Morbidity and Mortality” is an extremely complicated subject; however, at the same time it has been well studied and all modern health units in the World have a well-established system and policy to pursue the “Morbidity and Mortality” occurring in patients attending their facility. Several issues are to be considered in this important part of health care which need comments separately and individually and, in the end, can be put together to make some sense out of it.
Evaluating Risk.
Medical practitioners are all aware that every medical treatment may be drug therapy alone, procedure or operation carries an inherent risk to the patient. There are four variables that determine this risk to the patient including (i)- Type of intervention: For example, administering an antibiotic is safer than administering a drug for the treatment of cancer; doing appendix surgery is safer than doing brain surgery; doing a gastroscopy is safer than doing a colonoscopy, etc. (ii)- Patient health status: very sick patients are at higher risk than those healthy; children and elderly have a higher risk than adults; pregnant mother are at higher risk than non-pregnant women. (iii)- Hospital environment: hospitals with a clean environment are safer than those with dirty environments. (iv). Unknown and unusual: allergy to a drug is an unusual phenomenon and can put a patient to risk; an unusual reaction to a drug can happen due to altered and unknown factors in a patient.
Physician Responsibilities.
Every medical practitioner has 2 responsibilities in this regard namely evaluating the risk to the patient while instituting any treatment regimen and second to inform his patient about the possible risk. Extensive studies have been done in the medical literature to score the risk of any form of treatment to any type of patient under variable conditions and these scores need to be used by every medical practitioner. Computer-based formulas are available to score these risks and can be loaded in hand-held small pocket appliances (cell phones). Through this, we can easily quantify the risk to the patient after entering patient variables.
Consent.
Next, it is our responsibility to make the patient/his family aware of the inherent risk that he is undergoing while instituting the treatment, procedure, or surgery and take him/her into confidence. This is what we call “Consent” in the medical literature. Consent in clinical practice has 3 components namely (i)-full information to the patient about the type of treatment instituted, possible successes and failures with the treatment, and likely chances of the cure. (ii)-inherent risks of the treatment which may be remote, unusual, or expected, and their severity and nature. (iii)-alternative or other forms of treatment or opinions available and their accessibility to the patient. All patients must agree or sign a “Consent Form” before the treatment or procedure, or operation is instituted. This is a legal document that should protect the medical practitioner from possible criminal proceedings should his patient undergo the risk discussed.
Do No-Harm.
However, quantifying a risk and consenting a patient to the risk is only one aspect of the story. Important is how can we come up with the concept of “Do No-Harm” to our patients. This aspect of health care is what should differentiate a good from a bad health facility or a good from a bad health care delivery system. Five healthcare policies should be intensively followed to reach the status of doing “No harm” to our clients as listed below.
Internal Policy Procedures and Regulations- the so-called IPPRs.
One of the fundamental factors which make health units/hospitals anywhere in the world efficient is the policy of IPPRs followed in the system. What is IPPRs? IPPRs are policies and procedures, which define how health delivery is to be done in the index health unit depending on its strengths and weaknesses and seeing the community needs, the economical state of the caregiver or health unit, social and religious needs of the society. IPPRs of any healthcare unit include (i) Basic safety practices in hospitals like fire policy, disaster policy, and sanitation, etc. (ii) Hospital practices of major importance namely infection control, antibiotic policy, drug policy, narcotics usage policy, etc. (iii) Nursing practice policies for optimum nursing care. (iv) Material management policy of modern type which automatically identifies the quality and the level of availability of various items of varying importance.
Credentials:
All health units/hospitals in the world follow a policy of “Credentials” for their faculty. The system through an internal review determines the status of its faculty based on its Curriculum vitae, references, and overall experience and its own needs and certifies the faculty to do a set of procedures and surgeries. The health unit gives full support to the faculty to do that set of procedures and no more. The health unit/hospital also periodically reviews the outcome of the procedures done by the faculty. This way there is an internal check and balance that the faculty limits itself to only that set of procedures that are safe to be done in its environment and which can be efficiently done by the faculty. It has been seen that once a new faculty visits or introduces himself in the community he or she makes tall claims about the wonderful procedures he can do, or he can perform, and this takes the whole public and society by default and people follow the person in large numbers. Often such claims are not well founded, and many patients get harmed by this till the actual factual position is known. This is particularly true for visiting physicians and surgeons in a new place. In J&K there has been a trend of importing many physicians, surgeons, obstetricians, and laboratories from the rest of the countries and all such personnel make tall claims about their system and individuals. I believe this is an unhealthy trend and deceives and harms many patients. The state should define the credentials of each of such personnel for accurate information to the public.
Inservice.
Inservice education and training is an essential part that makes medical practice efficient and current. “Inservice” as it is commonly referred to in the West refers to initial and continuing training to health caregivers at all levels including general duty doctors, technicians, nurses, nurse support personnel, senior doctors, and health administrator. Low levels of health delivery among nursing, technicians, and medical practitioners are very common in our health delivery as they lack new information in an ever-changing field. Even the practice of doing a new job at the time of starting a new assignment is lacking in our system, exposing patients to medical personnel not well versed with the rules, regulations, and minimum safety standards of the job. This well-known system of education is so important in health delivery has never developed in our system. In North America, this system of education is the most important method, which has improved the quality of health care. It has become essential for any health delivery system in the World, which is successful. We must adopt in-service continuous medical education on the job policy intensely for all categories of healthcare workers. This needs extensive motivation on the part of health administrators. Western health delivery system has enforced a policy for certification for this training at the start and on a continuous basis. This means that medical personnel or a nurse or a technician cannot continue to practice medicine or his specialty unless he or she is exposed to certain in-service training on a continuous basis.
M&M Policy.
All hospitals and health units must follow M&M policy to accurately define the possible harm which may happen to patients and take early and effective measures to prevent a catastrophe. In this policy, the hospital has an M&M committee and this committee searches through the medical record of all morbidities and mortalities which happen in the hospital, and for each event, an explanation is sought through an ingenious review process. Index cases are discussed in an open forum for discussion and education. Periodic publications of infection rates, antibiotic sensitivity, morbidities, mortalities of procedures, and other important events are published for information to faculty and through them to the patients and public.
Medical Record.
Finally, all health units must have an efficient medical record, and this should be transparent and open to external review by the authorities and known to the public and society so that the efficiency of each unit can be graded on a scale as is done all over the World.
What sense can be made of all of this?
Morbidity and mortalities shall continue to happen in clinical practice as long as we continue to treat patients with drugs; procedures and operations; for each of these have inherent risks.
The question lies in whether we do enough in the following directions: (i)-inform patients about the risks; (ii)-be ready to identify the risk as early as possible; (iii)-manage the complication as soon as it occurs; (iv)- take corrective measures to prevent this complication in the next patient; (v)-gain the confidence of our patients and his family so that the pain of complication (morbidity and mortality) caused by us is absorbed. Once we do all this there shall be no massive public outcry, closure of the medical facility, criminal proceedings against the treating doctors, media hype, and a strong tremor in the whole medical community on the unfortunate death of the next patient.
(Prof Mohammad Sultan Khuroo is a renowned gastroenterologist. He can be mailed at khuroo@yahoo.com. mohammad.khuroo@gmail.com)
DISCLAIMER: The views and opinions expressed in this article are the personal opinions of the author.
The facts, analysis, assumptions and perspective appearing in the article do not reflect the views of GK.
