A lecture on clinical ethics consultations delivered to Alfarabi Medical College undergraduate medical students on 21.12.2016

1. Asst. Prof., Dept. of Medical Ethics
Alfarabi Colleges
Dr. Ghaiath M. A. Hussein
Professionalism and Ethics Education for Residents (PEER)
Medical Errors

2. Outline
 Definitions of terminology related to Medical Error (ME)
 Levels of severity of medical error
 Types & Examples of medical errors
 Causes of ME
 Disclosure of ME
 Prevention of Medical Error

3. Definitions of Medical Error
 The failure of a planned action to be completed as intended, or
as the use of a wrong plan to achieve an aim.
 A preventable adverse effect of care, whether or not it is evident
or harmful to the patient.
 This might include an inaccurate or incomplete diagnosis or
treatment of a disease, injury, syndrome, behavior, infection, or
other ailment.

4. More Definitions
 ME: An act or omission that would have been judged
wrong by knowledgeable peers at the time it occurred
 Adverse Event: An unplanned or unusual deviation in the
patient care
 Sentinel Event : An event which has resulted in an
unanticipated death or major permanent loss of function,
not related to the natural course of the patient's illness or
underlying condition.

5. Levels of Severity of ME
Level 1: An event occurred that resulted in the need for increased
patient assessments, but no change in vital signs and
no patient harm.
Level 2: An event occurred that resulted in the need for treatment
and/or intervention and caused temporary patient harm.
Level 3: An event occurred that resulted in initial or prolonged
hospitalization, and caused temporary harm.

6. Levels of Severity of ME Cont…
Level 4: An event occurred that resulted in permanent patient harm
or near death event, such as anaphylaxis.
Level 5: Any set of circumstances (exclusive of the disease or
condition in which the patient is being treated) which
significantly increases the likelihood of a serious
adverse outcome.
Level 6: An event occurred that resulted in patient death.
*Levels 3 through 6 shall be discussed with patient or families.

7. Types and Examples of Medical Errors
EXAMPLEERROR
Missed diagnosisDiagnosis or evaluation
Inappropriate or premature dischargeMedical decision-making
Waiting when treatment is indicatedTreatment
Incorrect dosageMedication
Failure to review treatment planInadequate supervision
Failure to convey informationFaulty communication
Faulty techniqueProcedural complications
Inappropriate or premature dischargeMedical decision-making
*Wu AW, McPhee SJ, and Christensen JF. Mistakes in Medical Practice, Chapter 32 in Behavioral Medicine in Primary
Care. 1997 Appleton and Lange, Stamford, CT. Edited by MD Feldman and JF Christensen.
*Adapted, with permission, from Wu AW at al: Do house officers learn from their mistakes? JAMA 1991;
265:2089. American Medical Association

8. Common Causes of Medical Mistakes
 Ignorance
 Inexperience
 Faulty judgment
 Hesitation
 Fatigue
 Job overload
 Breaks in concentration
 Faulty communication
 Failure to monitor closely
 System flaws
*Wu AW, McPhee SJ, and Christensen JF. Mistakes in MedicalPractice,Chapter 32 in Behavioral Medicine in Primary Care. 1997
Appleton and Lange, Stamford, CT. Edited by MD Feldman and
JF Christensen.

9. Simple Truths about Medical Mistakes
1. Errors will happen. Since no human is infallible, errors are bound
to happen, and this includes physicians.
2. Since errors can be expected, systems must be designed to
prevent and absorb them.
3. Errors are not synonymous with negligence. Medicine’s ethos of
infallibility leads, wrongly, to a culture that sees mistakes as an
individual problem and remedies them with blame and
punishment instead of looking for root causes and fixing problems
by improving systems.
4. Creating a culture supportive of errors reporting is the starting
point in reducing future medical errors.

10. Disclosing Error to Patients
Notify your professional insurer and seek assistance
from those who might help you with disclosure (e.g.,
unit director, risk manager)
Disclose promptly what you know about the event.
Concentrate on what happened and the possible
consequences.
Take the lead in disclosure; don’t wait for the patient
to ask.

11. Disclosing Error to Patients Cont.
 Outline a plan of care to rectify the harm and prevent
recurrence.
 Offer to get prompt second opinions where appropriate.
 Offer the option of a family meeting and the option of
having lawyers present.
 Document important discussions.

12. Disclosing Error to Patients Cont.
 Offer the option of follow-up meetings.
 Be prepared for strong emotions.
 Accept responsibility for outcomes, but avoid attributions of
blame.
 Apologies and expressions of sorrow are appropriate.
Hébert PC, Levin AV, and Robertson G. CMAJ 2001:164; 509-513

13. Prevention of Medical Errors
Examples in medical practiceError prevention measures include
Checklists, flow sheets, tickler
systems
Reduced reliance on memory
Handheld computer, electronic
medical records
Improved information access
Fail-safe to avoid prescribing two
drugs that interact fatally
Error-proofing systems.
Office formularies, guidelines
synthesis
Standardization
Staff in services.Training on error identification and
prevention

14. ‫والنظامية‬ ‫القانونية‬ ‫الجوانب‬
‫إلى‬ ‫تنقسم‬ ‫الطبية‬ ‫المخالفات‬:
•‫عادية‬ ‫مخالفات‬(‫نظامية‬،‫وشرعية‬)‫ا‬ ‫باألصول‬ ‫لها‬ ‫صلة‬ ‫ال‬ ‫التي‬‫لفنية‬
‫ومن‬ ،‫الطب‬ ‫لمهنة‬‫أبرزها‬:‫ممارسة‬‫الجهة‬ ‫من‬ ‫ترخيص‬ ‫دون‬ ‫الطبي‬ ‫العمل‬
‫بيانات‬ ‫أو‬ ،‫مشروعة‬ ‫غير‬ ‫بطرق‬ ‫ا‬ً‫ص‬‫ترخي‬ ‫استحصل‬ ‫من‬ ‫ومثلها‬ ،‫الحكومية‬‫غير‬
‫ل‬ ‫أهل‬ ‫أنه‬ ‫يعتقد‬ ‫الجمهور‬ ‫تجعل‬ ‫دعائية‬ ‫وسيلة‬ ‫استعمل‬ ‫أو‬ ،‫للحقيقة‬ ‫مطابقة‬‫مزاولة‬
‫عل‬ ‫طلق‬ُ‫ت‬ ‫التي‬ ‫األلقاب‬ ‫من‬ ‫ا‬ً‫ب‬‫لق‬ ‫انتحل‬ ‫أو‬ ‫للحقيقة‬ ‫ا‬ً‫ف‬‫خال‬ ،‫طبي‬ ‫عمل‬‫مهنة‬ ‫مزاولي‬ ‫ى‬
‫الطب‬.
•‫فنية‬ ‫مخالفات‬:
‫وهي‬‫والمقص‬ ،‫الفنية‬ ‫والقواعد‬ ‫األصول‬ ‫على‬ ‫الطبيب‬ ‫فيها‬ ‫يخرج‬ ‫التي‬ ‫األخطاء‬‫ود‬
‫والقواعد‬ ‫باألصول‬:‫وعمل‬ ً‫ا‬‫نظري‬ ‫عليها‬ ‫المتعارف‬ ‫والقواعد‬ ‫الثابتة‬ ‫األصول‬‫بين‬ ً‫ا‬‫ي‬
‫علوم‬ ‫كانت‬ ‫سواء‬ ‫الطبي‬ ‫العمل‬ ‫وقت‬ ‫طبيب‬ ‫كل‬ ‫بها‬ ‫يلم‬ ‫أن‬ ‫يجب‬ ‫التي‬ ‫األطباء‬‫مقررة‬ ً‫ا‬
‫ب‬ ‫علمية‬ ً‫ال‬‫أصو‬ ‫تعتبر‬ ‫فهذه‬ ‫اكتشافها‬ ‫طرأ‬ ‫مستحدثة‬ ً‫ا‬‫علوم‬ ‫أكانت‬ ‫أو‬ ‫قديمة‬‫شرطين‬:
1-‫الطبيـة‬ ‫باألبحاث‬ ‫المختصة‬ ‫الجهات‬ ‫مثـل‬ ‫معتبرة‬ ‫جهة‬ ‫من‬ ‫صادرة‬ ‫تكون‬ ‫أن‬.
2-‫بكفاءتـها‬ ‫الخبـرة‬ ‫أهل‬ ‫يشـهــد‬ ‫أن‬.

15. ‫والنظامية‬ ‫القانونية‬ ‫الجوانب‬
•‫قسمين‬ ‫على‬ ‫تنقسم‬ ‫الفنية‬ ‫األخطاء‬:
–‫خطأ‬‫التشخيص‬ ‫في‬
–‫وخطأ‬‫الفعل‬ ‫في‬.
‫للضمان‬ ‫الموجب‬ ‫الخطأ‬‫الن‬ ‫يحتمل‬ ‫ال‬ ،ً‫ا‬‫فاحش‬ ‫خطأ‬ ‫يكون‬ ‫أن‬ ‫من‬ ‫بد‬ ‫ال‬‫قاش‬
‫نتيج‬ ‫إال‬ ‫يحصل‬ ‫ال‬ ‫الحال‬ ‫بطبيعة‬ ‫وهذا‬ ،‫اآلراء‬ ‫فيه‬ ‫تختلف‬ ‫وال‬ ‫الفني‬‫أو‬ ‫الجهل‬ ‫ة‬
‫الرعونة‬ ‫أو‬ ‫اإلهمال‬.
‫جراح‬ ‫أو‬ ‫طبيب‬ ‫فيه‬ ‫يقع‬ ‫أن‬ ‫يمكن‬ ‫ال‬ ‫الذي‬ ‫هو‬ ‫الفاحش‬ ‫أو‬ ‫الجسيم‬ ‫والخطأ‬
‫ن‬ ‫المهنة‬ ‫في‬ ‫متوسط‬ ‫طبيب‬ ‫يفعله‬ ‫ما‬ ‫المعالج‬ ‫الطبيب‬ ‫فعل‬ ‫فإذا‬ ،‫مماثل‬‫فســها‬
‫بالخطأ‬ ‫يوصف‬ ‫ال‬ ‫سلوكه‬ ‫فـإن‬ ‫نفسها‬ ‫الظـروف‬ ‫في‬ ‫والمســتـوى‬

16. ‫والنظامية‬ ‫القانونية‬ ‫الجوانب‬
‫الشرعية‬ ‫الطبية‬ ‫اللجنة‬

17. ‫والنظامية‬ ‫القانونية‬ ‫الجوانب‬
‫كيفية‬‫اإلثبات‬
•‫يعتمد‬‫ال‬ ‫اإلثبات‬ ‫أدلة‬ ‫على‬ ‫المسؤولية‬ ‫موجب‬ ‫إثبات‬ ‫في‬ ‫القاضي‬‫شرعية‬
‫التي‬‫منها‬:
.1‫اإلقرار‬‫األدلة‬ ‫أقوى‬ ‫وهو‬:‫الحكم‬ ‫القاضي‬ ‫يثبت‬ ‫كاملة‬ ‫حجة‬ ‫واإلقرار‬
‫بحق‬ ً‫ا‬‫مرتبط‬ ‫دام‬ ‫ما‬ ‫أنكره‬ ‫أو‬ ‫إقراره‬ ‫عن‬ ‫رجع‬ ‫ولو‬ ‫إليها‬ ً‫ا‬‫استناد‬‫أ‬‫دمي‬.
.2‫الشهادة‬،‫معين‬ ‫فعل‬ ‫على‬ ‫مساعد‬ ‫أو‬ ‫ممرض‬ ‫أو‬ ‫آخر‬ ‫طبيب‬ ‫شهادة‬ ‫مثل‬
‫م‬ ‫فيها‬ ‫يشترط‬ ‫فإنه‬ ‫معينة‬ ‫واقعة‬ ‫حصول‬ ‫على‬ ‫الشهادة‬ ‫كانت‬ ‫فإذا‬‫يشترط‬ ‫ا‬
‫مخ‬ ‫أو‬ ‫اإلجراء‬ ‫في‬ ‫التقصير‬ ‫على‬ ‫الشهادة‬ ‫وأما‬ ،‫بعامة‬ ‫اإلثبات‬ ‫في‬‫الفة‬
‫خبرة‬ ‫أهل‬ ‫من‬ ‫إال‬ ‫يقبل‬ ‫ال‬ ‫فهذا‬ ‫العلمية‬ ‫األصول‬‫واختصاص‬.
.3‫المستندات‬‫المستشفي‬ ‫سجالت‬ ‫في‬ ‫الموجودة‬ ‫والتقارير‬ ‫الخطية‬‫ات‬،
‫العبث‬ ‫من‬ ‫عليها‬ ‫يحافظ‬ ‫وأن‬ ‫خاصة‬ ‫حماية‬ ‫لها‬ ‫يكون‬ ‫أن‬ ‫بشرط‬.

18. ‫والنظامية‬ ‫القانونية‬ ‫الجوانب‬
•‫أثر‬‫اإلثبات‬(‫الخاص‬ ‫والحق‬ ‫العام‬ ‫الحق‬)
•‫الخطأ‬ ‫كان‬ ‫إذا‬‫ترخ‬ ‫دون‬ ‫من‬ ‫العمل‬ ‫ممارسة‬ ‫مثل‬ ‫به‬ ‫للمريض‬ ‫عالقة‬ ‫ال‬ ً‫ا‬‫محض‬ ً‫ا‬‫نظامي‬‫يص‬
‫مهنة‬ ‫مزاولة‬ ‫نظام‬ ‫في‬ ‫محددة‬ ‫وعقوبته‬ ‫العام‬ ‫للحق‬ ‫راجع‬ ‫فهذا‬‫الطب‬.
•‫أما‬‫ف‬ ‫المرض‬ ‫تحقيق‬ ‫أو‬ ‫الشفاء‬ ‫منه‬ ‫يقصد‬ ‫معين‬ ‫بإجراء‬ ‫للطبيب‬ ‫المريض‬ ‫أذن‬ ‫إذا‬‫أجراه‬
‫ال‬ ‫على‬ ‫ضمان‬ ‫فال‬ ‫نفس‬ ‫أو‬ ‫عضو‬ ‫تلف‬ ‫عليه‬ ‫فترتب‬ ‫العلمية‬ ‫األصول‬ ‫وفق‬ ‫على‬‫باتفاق‬ ‫طبيب‬
‫أهل‬‫العلم‬.
•‫والحق‬‫أربعة‬ ‫مسؤولية‬ ‫فيه‬ ‫الطبيب‬ ‫يلحق‬ ‫الذي‬ ‫الخاص‬‫أمور‬:
.1‫كون‬‫غير‬ ‫الطبيب‬‫مؤهل‬.
.2‫مخالفة‬‫لألصول‬ ‫الطبيب‬‫العلمية‬.
.3‫كونه‬‫مأذون‬ ‫غير‬‫له‬.
.4‫ال‬ ‫بحيث‬ ‫الجناية‬ ‫تعمد‬‫ك‬ ‫مشروعة‬ ‫مصلحة‬ ‫تحقيق‬ ‫أو‬ ‫الشفاء‬ ‫إلى‬ ‫عمله‬ ‫من‬ ‫يهدف‬‫عمليات‬
‫وغيرها‬ ‫الرحمة‬ ‫وموت‬ ‫المحرم‬ ‫واإلجهاض‬ ‫الجنس‬ ‫وتغيير‬ ‫التحسينية‬ ‫التجميل‬.
‫الخاص‬ ‫الحق‬ ‫في‬ ‫للمسؤولية‬ ‫موجبة‬ ‫األمور‬ ‫وهذه‬.

19. ‫الهيئة‬‫احكام‬‫من‬‫مثال‬

20. Questions for Discussion
 How do I decide whether to tell a patient about an error?
 Do physicians have an ethical duty to disclose information about
medical mistakes they, or their colleagues, did to their patients?
 Won't disclosing mistakes to patients undermine their trust in
physicians and the medical system?
 By disclosing a mistake to my patient, do I risk having a malpractice suit
filed against me?
 What if I see someone else make a mistake?
http://depts.washington.edu/bioethx/topics/mistks.html

21. THANKS FOR YOUR
ATTENTION