Psychiatry and psychology Stars

How to avoid medical errors

2012-08-22

Even in ancient times it was believed that if the patient did not feel better immediately after a visit to the doctor, it means that he turned to a bad specialist. The old scheme of the doctor-patient relationship, when the doctor knows everything, and the patient is obliged to obey him, no longer works. The realities of modern medicine dictate the need to build partnerships with the patient. This obliges doctors to inform patients in detail and in an accessible form both about the alleged disease and / or the range of diagnostic search, and to explain the need and possible complications medical manipulations.

With this scheme of building relationships, the emergence of conflict situations is inevitable. Correctly executed medical documentation is the only proof of the doctor's innocence. And the more signs of the patient's direct involvement in the process of diagnosis and treatment, the better. This applies not only to informed consent to invasive, complex and expensive methods of diagnosis and treatment, correctly drawn up from a legal point of view, but also to informed refusal from them, which doctors often forget.

Be professional

Almost half of patients seek medical help for reasons deeper than the main complaint expressed. Complaints can only be a legitimate pretext for seeking medical attention. It is imperative to let the patient speak, especially at the first visit.

It is necessary to remember to maintain interpersonal distance, this reduces the risk of manipulation by the patient. Be sure to remind the patient of the confidentiality of the conversation. It is undesirable to start a conversation with a topic that is difficult for the patient. It is best to approach the most exciting and sensitive issues gradually. Avoid using medical terms... Inform him about treatment measures and expected results within the professional competence. Do not ask the patient to name the exact names of the items of care and drugs; if necessary, ask to simply show them. Also, one should not expect that the patient will remember the names of employees, room numbers. If necessary, the information is presented on paper and left to the patient. You cannot create a feeling of guilt in the patient for inaccurate execution of instructions or recommendations. Whenever possible, he is given clear and specific advice and recommendations.

Don't simulate hectic activity

The times when a patient, getting to the hospital for the treatment of bronchitis, underwent a full circle of medical examination, are irrevocably gone. Nevertheless, a huge number of patients still believe that the doctor is simply obliged to fulfill their every desire, not wanting to delve into the specifics of therapy standards and VHI. It should be admitted that we ourselves are largely to blame for this, being afraid at the right time to refuse to conduct an unreasonable method of examination or treatment. In part, this situation is aggravated by the psychology inherent in our patients - if they put on a dropper, then the doctor is good, if he canceled everything, then he is bad.

Do not advise by phone

When making consent with the general plan of examination and treatment, the patient, in addition to consent to the processing of his medical data, must clearly indicate to whom and to what extent the attending physician can transfer information about his health. Do not forget that telephone communication is a conversation between two "blind" people. Moreover, every word you say can be recorded and then used against you as material evidence.

Once you pick up the phone, you accept responsibility for solving the patient's problems, even if it is not part of your job. Try to avoid unambiguous interpretations of new symptoms and making a decision to change drug therapy. Always try to listen carefully to the patient, especially for calls containing a complaint. In any case, you need to remain completely calm: the more aggressive your interlocutor, the more calm you yourself should show! It is very important that the caller has no doubt that his problem has been heard.

Speak the truth

Often a situation arises when the patient's relatives categorically do not recommend informing him about the detection of any serious diseases. However, at present, according to the law, a patient, when contacting a healthcare institution or a private practitioner, has the right to receive complete and reliable information about services. This right is enshrined in Article 10 of the Law of the Russian Federation "On Protection of Consumer Rights" and paragraph 10 of the Rules for the provision of paid medical services to the population.

Thus, at present the doctor has no right not to notify the patient about the presence of any disease, including an incurable disease.

Don't say too much

Remember that any information coming from you may ultimately become a reason for a claim, up to a legal claim. This also applies to the medical history, which the patient has the right to copy in any way convenient for him. It is better not to inform the patient about what you are not 100% sure of, if you do not want to answer the constant questions: "Doctor, can this pimple on the forehead be a terrible tumor?"

Share responsibility

Research shows that patients who are more actively involved in their own treatment have not only a better chance of preventing medical error, but also of coping with the disease.

Be sure to negotiate with the patient: to whom of his relatives or friends you can transfer information about his state of health. The patient must personally identify each person by name. Calls from young relatives sharing an inheritance are now by no means uncommon.

When solving complex ambiguous medical problems, a potential threat to the patient's life, gather a consultation with the participation of the necessary specialists and, if possible, including the patient himself or his legal representative appointed by the court. Remember that you can only recommend using this or that method, the final decision should remain with the patient.

Double-check the information

Everybody lies. This applies not only to patients, but also to the results of diagnostic studies, in which inaccuracies and errors often creep in. Collection error and / or misinterpretation of anamnesis, including by the patient himself, is one of the most common causes of medical errors. Also try to double-check the information coming from the patient's relatives.

Write as is

If during the round the patient is not in the ward, then you should not invent a non-existent examination indicating hemodynamic values, etc. Remember that not only you, but also the patient can double-check the correctness of your medical records. When negativism appears in the patient's behavior, it is also highly desirable to immediately indicate this in the medical history, if necessary, notifying the higher authorities. Practice shows that such an approach avoids the development of many conflict situations in the early stages.

Errors in the provision of emergency care are usually attributed to improper actions or inaction of medical personnel that caused or could cause a deterioration in the patient's condition or death.

A medical error as a legal category is a conscientious delusion of a doctor without signs of criminal negligence: criminal negligence (neglect of a visible or known danger), criminal arrogance (unjustified hope of avoiding complications) or criminal ignorance (lack of professional knowledge, if it is possible to obtain them) [Zilber A. P., 1994]. Therefore, actually for a mistake, regardless of its consequences, the doctor cannot bear criminal, disciplinary or other responsibility. Responsibility arises in cases when, among the reasons that led to a medical error, there are signs of negligence, criminal negligence or violation of the current legislation of the Russian Federation.

One of the features of medical errors in urgent cardiac conditions is that, due to the high probability of a sudden sharp deterioration in the condition (up to the cessation of blood circulation), there may not be time to correct them.

Errors can be divided into diagnostic, therapeutic, tactical, and deontological errors.

Diagnostic errors

Diagnostic errors consist in the fact that the main and concomitant diseases, as well as their complications, are incorrectly or incompletely established, and the wording of the diagnosis is not categorized or does not correspond to the current 10th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10 ).

According to R. Hagglin (1993), the following factors can lead to an incorrect diagnosis:

a) ignorance;

b) insufficient examination due to:

Lack of opportunities;

Lack of time;

Bad technique;

c) errors in judgment due to:

Atypical course of the disease;

Prevailing stereotypes;

Lack of constructive thinking;

Attitudes towards the accuracy of your diagnosis;

Bias of opinion;

Self-love and vanity;

Illegal conclusions;

Indecision of character;

Striving to make especially "interesting" diagnoses;

Striving not to go beyond the "hackneyed" diagnoses;

Other character traits, such as a tendency to pessimism or excessive optimism,

Let us add that sometimes the cause of diagnostic errors is ignoring the absence of a necessary (or the presence of an "extra") symptom.

In emergency cardiology, diagnostic errors are primarily due to the severity of the patient's condition, lack of conditions, and most importantly - the time for examination, consultation and follow-up.

Not always insufficient equipment with diagnostic equipment (for urgent ultrasound,

x-ray, laboratory research) is critical.

Most often, the cause of diagnostic errors is the inability to purposefully and fully collect and correctly evaluate the available information about the patient: complaints, medical history, life history, data from physical and instrumental, primarily electrocardiographic, studies.

Healing mistakes

Errors in the conduct of emergency treatment are manifested by significant and unreasonable deviations from the existing local, regional or national standards or the established unwritten principles of emergency assistance... According to V.F. Chavpetsov et al. (1989), treatment errors are manifested in the following:

Medicines and therapeutic manipulations that are indicated are not prescribed;

The indicated drugs or therapeutic manipulations are applied incorrectly (out of time, the dose, method, speed, frequency of administration or technique of execution were chosen incorrectly);

Prescribed drugs not shown or medical manipulations;

Irrational combinations of drugs or therapeutic manipulations are used;

Contraindicated medications or medical manipulations are used.

The main causes of errors in emergency treatment are subjective. The lack of necessary medicines, solutions, apparatus or instruments can be of some importance. True, sometimes this same circumstance reduces the aggressiveness of treatment and the threat to the life and health of the patient arising from unjustified intensive therapy.

The most common mistakes in the provision of emergency care, undoubtedly, are the prescription of drugs or medical manipulations without sufficient indications, poly-pragmasy, the use of the notorious medicinal "kokteilei".

Another, no less dangerous group of errors in treatment includes excessively fast intravenous administration potent drugs; the use of such drugs and methods of administration in which it is difficult to control their effect. A classic example is the unacceptably rapid intravenous administration of novocainamide. It is believed that the rate of intravenous infusion of this drug should not exceed 30 mg / min. Usually, especially at the prehospital stage, this procedure does not take more than 5 minutes, i.e. the drug is administered at a rate of 200 mg / min.

Another typical and dangerous mistake is that the effect of drugs that the patient is constantly treated with or that were used immediately before the provision of emergency care is not taken into account. For example, against the background of planned treatment with blockers (3-adrenergic receptors are administered verapamil. The consequences of an error of this kind (arterial hypotension, severe bradycardia) cannot always be eliminated.

Failure to knowingly use the drug should be considered a serious treatment error. effective methods providing emergency medical care... In particular, such errors can be attributed to unjustified refusal to conduct thrombolytic therapy for large-focal myocardial infarction (Chapter 6).

Tactical mistakes

Tactical errors in the provision of emergency care are errors in determining the continuity of treatment, that is, untimely or non-core transfer of the patient to specialists at the point of care or during hospitalization.

Usually, tactical errors result from diagnostic errors, which, in turn, lead to therapeutic ones. At the prehospital stage, tactical mistakes, as a rule, consist in untimely hospitalization of the patient, less often in untimely unreasonable or non-core call of a specialized team. It should be noted that late hospitalization can rarely be justified by the patient's refusal to inpatient treatment, more often it is a consequence of deontological (inability to find contact with the patient) error.

Deontological errors

Deontological mistakes consist in the doctor's inability (sometimes lack of strength or desire) to find contact with the patient and others, underestimation of the danger of careless remarks, failure to use psychotherapeutic methods of treatment in the provision of emergency care. To paraphrase Confucius, we can say that one who does not know the power of words can neither know nor heal a person.

Deontological errors usually lead to incorrect collection of information, and hence - to incorrect diagnosis and treatment, and remain one of the main reasons for claims to the quality of medical care.

It is obvious that diagnostic, therapeutic, tactical and deontological errors are interconnected, often caused by the same reasons and follow from one another. A significant number of errors depend on subjective factors, and many new ones arise due to insufficient professional assessment of old ones.

Error prevention

Each time you provide emergency care, you should consider:

The severity of the patient's condition (the degree of acute circulatory disorders);

The likelihood of life-threatening complications (the presence of a direct threat of acute circulatory disorders);

The main and concomitant diseases and their complications;

The immediate cause and mechanism of the emergency;

Factors supporting and aggravating the emergency;

The patient's age;

Previous treatment and past drug reactions;

The possibility of applying the appropriate recommendations for urgent cardiac care;

Features of an emergency;

If necessary, the degree of probability of the diagnosis (definite, presumptive), the priority areas of differential diagnosis (with which diseases should be differentiated in the first place) should be specified.

6. Assessment of the clinical situation:

The severity of the condition;

The severity of acute circulatory disorders or the direct danger of its occurrence;

Lead (s) syndrome (s);

Features of an emergency;

Probable forecast;

Necessity and possibility of emergency receipt additional information, help from specialists.

7. First aid:

Medicines: time (beginning, end, rate of administration), dose, method of administration, response to application, side effects;

Therapeutic manipulations: time of treatment (beginning, end), equipment used, technical difficulties, reaction to treatment, complications.

8. Changes in the patient's well-being and condition (complaints, clinical, instrumental, laboratory data, the results of monitoring vital functions, etc.) over time (in time and in the stages of emergency care).

9. Supportive treatment, preventive measures, recommendations for the patient.

10. Continuity in the provision of medical care (to whom, at what time, in what condition the patient was transferred).

In case of emergency hospitalization, the official hospital referral forms are used. In addition, it is important to refer the patient directly to a specialist and provide more complete information about him. It is convenient to do this by filling out a formalized emergency card with a carbon copy. It is important not to forget to take to the hospital all the medical documentation that is relevant for this case that the patient has at home (outpatient card, certificates, electrocardiograms, etc.).

Each of us uses medical services - both paid and free.

For various reasons, we go to the clinic, entrust our health and lives to doctors. In return, we expect to receive qualified, timely assistance and proper treatment.

Unfortunately, in reality, medical errors are inevitable. Their number is growing every year, as is the number of complaints of patients against doctors for illiterate or inopportune medical care.

What to do and where to go if you did not receive medical assistance or if the doctor's carelessness led to a serious health problem?

What is a medical error?

The law does not contain the concept of medical error. But the main reference point was given by Professor Davydovsky back in 1941.

A medical error is a conscientious delusion of a doctor, which does not contain corpus delicti and is based on the imperfection of the current state of medical science and research methods.

At the same time, the delusion is based on the special course of the patient's disease or on the lack of experience and knowledge of the doctor, but without elements of negligence, negligence and professional ignorance.

A medical error is a delusion of a medical professional, which led to adverse consequences for the patient, up to and including death.

Medical error rules out bad faith or in relation to patients.

Classification and causes of medical errors

It is easy to see that the vagueness of the definition of a medical error opens the way to permissiveness. Such an act is difficult to prove. Therefore, it is important to highlight its qualifying features.

These signs include:

• tactical - improper organization of the treatment process;
• technical - incorrect execution of medical documentation;
• diagnostic, remedial errors and errors in prevention. This is a conditional division, since diagnostic and therapeutic are closely related.

Also, special attention should be paid to the causes of medical errors. There are objective and subjective reasons for a medical error.

TO objective include:

• shortcomings in the organization of health care, including advanced training of doctors;
• objective diagnostic difficulties - short-term (up to 3 days) stay of the patient in the hospital, serious condition of the patient, difficulty in diagnosis.

TO subjective include:

• personal characteristics of the doctor, lack of sufficient experience and qualifications;
• insufficient, bad or incorrect research and observation;
• insufficient knowledge;
• incorrect assessment of data or incorrect conclusions.

Often it is the doctor's incompetence that becomes the cause of medical error.

Where to go in case of medical error?

The consequences of medical errors can be dire, up to the death of a patient. At the same time, it is extremely difficult to prove that the harm to health was caused precisely by unprofessional actions of the doctor, but it is possible.

Use all possible options:

• Contact the head physician of the medical institution

If you think that you have received the wrong treatment, you should contact the head physician of the hospital with a statement. This must be done first.

Your application will be checked. The results will be notified within 30 days.

The medical institution can meet you halfway and offer solutions to the problem - additional treatment or compensation. This method is suitable if we are not talking about a lot of damage.

• Contact the insurance company

The option is acceptable when it comes to large monetary compensation.

If you were treated under a compulsory medical insurance agreement, then you will need to collect a certain package of documents for applying:

1. a copy of the medical record or an extract from the medical history. They must be provided to you at the institution where you received treatment;
2. statement - in it indicate where you received treatment, in what time frame, what diagnosis was made, who was the attending physician, what procedures you underwent, what damage was caused.
3. documents confirming the amount of damage.

Not only the doctor is responsible for causing harm to the patient, but also the medical institution in which he works.

The received application is considered by the management of the medical institution within 10 days.

If the fact of medical error is disputed, an independent medical examination... Based on its results, the amount of compensation for material damage is assigned, which is drawn up by a special order of the head of the medical institution. It indicates the amount and terms of compensation. The money is transferred to your bank account.

Remember that you must be given a copy of the compensation order.

• File a lawsuit

You should go to court to recover compensation for property and moral harm caused to your health. File a statement of claim and attach the results of the IMR.

As part of the legal process, in addition to compensation for damage, you can demand to bring to disciplinary, administrative or criminal liability a medical worker who made a medical error.

Compensation for material and moral damage is recovered through the court.

If you have used the services of a private clinic, for example, dentistry, then you should send a claim before going to court. This is a mandatory rule.

Guided by the Law of the Russian Federation "On Protection of Consumer Rights", you have the right to demand compensation for poorly provided services. If the clinic refuses, feel free to file a lawsuit.

Before filing a claim in court against a private clinic, send a claim with a claim for compensation for material damage.

Based on Art. 1085 of the Civil Code of the Russian Federation, you also have the right to demand compensation for earnings lost due to loss of health.

• To the prosecutor's office

This authority should be contacted when a criminal case is to be brought against a doctor. For example, in the case of causing irreversible harm to health or causing death by negligence.

Criminal liability of a doctor for a mistake

For a medical error, a healthcare professional can be held accountable:

• disciplinary (reprimand, reprimand, dismissal, loss of bonus);
• civil law (compensation for damage in full through the court and compensation for moral damage);
• criminal.

A doctor can be held criminally liable for causing grievous bodily harm or death of a patient.

What article of the Criminal Code of the Russian Federation threatens for medical error?

The medical worker will be punished under Art. 118 of the Criminal Code of the Russian Federation for causing grievous harm to the patient's health in the form of:

• restrictions on freedom up to 4 years;
• forced labor up to 1 year;
• imprisonment for up to 1 year.

An additional sanction is deprivation of the right to work in the medical field for up to 3 years.

For a medical error that resulted in serious harm to the patient's health, a doctor can "thunder" in prison for a year.

If the actions of the health worker led to the death of the patient due to improper performance of his professional duties, then he will be judged under Art. 109 of the Criminal Code of the Russian Federation. The court has the right to appoint:

• restriction of freedom for 3 years;
• forced labor up to 3 years;
• imprisonment for 3 years.

Additionally, a doctor may be deprived of the right to practice medicine for 3 years.

For the death of a patient caused by negligence, the doctor faces a prison term of up to 3 years.

For HIV infection, a medical worker faces punishment under Art. 122 of the Criminal Code of the Russian Federation in the form:

• forced labor up to 5 years;
• imprisonment for 5 years.

The court also has the right to deprive a doctor of the opportunity to work in medical institutions for 3 years.

Remember that proving a medical error is problematic. And it is better to enlist the support of an experienced lawyer in advance in order to punish an unscrupulous healthcare professional for unprofessionalism.

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

CHARACTERISTIC MEDICAL ERRORS
IN TREATMENT OF SEVERE ACUTE PANCREATITIS

(manual for doctors)

Part 1. Typical errors and their classification.

Saint Petersburg, 2005

INTRODUCTION

This manual for doctors is devoted to a problem that has received little and reluctance to write about. Nevertheless, the subject 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 moving on to the materials of the proposed manual, we should, if possible, briefly give the trained doctor a modern definition of medical error, which is an inevitable shadow of clinical practice.

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

According to the Russian press, 190,000 patients die from medical errors in US hospitals every year. ["Science and life. 2005 No. 5 p. 100.]... However, the USA 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 errors is scarce. ABOUT own mistakes doctors write rarely and reluctantly.

This manual is addressed, first of all, to the heads of surgical departments, leading surgeons of hospitals in which patients with severe acute pancreatitis are assisted, as well as methodologists and students: clinical residents, graduate students and interns.

Let's return to the topic of medical errors, which we will supplement with several cases from the practice of treating pancreatic necrosis, which is 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 deal with errors in the diagnosis and treatment of severe acute pancreatitis. The lack of publications dealing with 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, in general, is unproductive and limited rare descriptions special cases of medical and diagnostic errors.

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

Definitions of medical error

Here are a few 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 disruption of the implementation of medical technologies, an increase or not a decrease in the risk of progression of the patient's disease, as well as the risk of new pathological process. The suboptimal use of health care resources is also referred to as a "medical error" (Komorovsky Yu.T., 1976).

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

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

Most of The above definitions were taken from the official website of the territorial fund of compulsory health insurance, 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 No.
In modern, especially foreign, literature, the indicator of the quality of medical care is used as an integrating one.

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

Medical 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 treatment and diagnostic errors, orders, "protocols", evidence-based recommendations, treatment and diagnostic algorithms and, finally, standards have been developed in Russia and abroad, which are designed to reduce the frequency and risk of treatment and diagnostic errors made by doctors of prehospital and hospital stages of the "ambulance" service.

Based on the guidance documents developed by such organizations as the British Society of Gastroenterologists 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 North-West 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 treatment measures for the first time in our country it 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 appropriate medical and diagnostic measures at the turn of the 20th and 20th centuries are reflected in the "Diagnostic and Treatment Protocols. Acute pancreatitis. " SPb, 2004], approved by the Association of Surgeons of the North-West of the Russian Federation on March 12, 2004.

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

In the late XX and early XXI centuries. new theoretical concepts, new methods of diagnosis and treatment have appeared, also associated with the risk of developing previously unknown dangers, errors and complications.

Krakovsky N.I. and Gritsman Yu.Ya. (1967) to surgical errors include all actions of the surgeon that involuntarily 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. The administrative aspect of the doctor's mistakes extends, according to Komarovsky, from "delusion" and "accident" to "misconduct" or "crime".

This exhaustively complete and, as a consequence, overcomplicated classification, encompasses all types, stages, causes, consequences and categories of medical errors that are currently conceivable.

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, the admission department of the hospital, in the process of examination, diagnosis, establishment indications for a particular treatment method at all stages of inpatient treatment (surgical or conservative), both in the preoperative and postoperative periods.

As follows from this "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 "typical medical errors" may be due to the peculiarities of the pathology, the degree of its complexity and knowledge, etc.

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

1. Types of medical errors

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

1.2. Therapeutic: general, tactical, technical.

1.3. Organizational: administrative, documentary, deontological.

2. Stages of medical errors

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

2.2. Inpatient: preoperative, operational, postoperative.

2.3. Post-stationary: adaptive, convalescent, rehabilitation.

3. Causes of medical errors

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

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

4. Consequences of medical errors

4.1. Minor: temporary disability; unnecessary hospitalization;

4.2. Unnecessary treatment, disability, death.

1.1. Types of diagnostic errors

1.1.1. For diseases and complications: for the main, competing and associated diseases; for concomitant and underlying diseases; on complications of diseases and treatment.

1.1.2. By the quality and formulation of diagnoses: unidentified (no diagnosis in the presence of a disease); false (the presence of a diagnosis in the absence of a disease); incorrect (unmatched in the presence of another disease); erroneous (there is no named disease); viewed (the disease you are looking for is not named); untimely (late, belated); incomplete (the necessary components of the diagnosis are not named); inaccurate (bad wording and wording); ill-considered (unsuccessful interpretation and placement of the components of the diagnosis.

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

1.2. Types of treatment errors

1.2.1. Are common: not indicated, incorrect, insufficient, excessive, delayed treatment; incorrect and untimely correction of metabolism (water-salt balance, acid-base balance, carbohydrate, protein and vitamin metabolism); incorrect and untimely choice and dosage of medications, physiotherapy procedures and radiation therapy; prescription of incompatible combinations and misuse 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, the wrong choice of anesthesia and operative access, inadequate revision of organs; incorrect assessment of the reserve capabilities of the body, the volume and method of surgery, the sequence of its main stages, insufficient drainage of the wound, etc.

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

1.3. Types of organizational mistakes

1.3.1. Administrative mistakes are just as varied, from inefficient hospital planning to insufficient quality control and efficiency of treatment.

1.3.2. Documentation: from incorrect execution of the protocols of the operation, documentation, certificates, extracts from case histories, sick leaves; shortcomings and gaps in the design of outpatient cards, case histories, operational log; defective logs and the like.

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

2. Subjective causes of medical errors

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

3. Typical errors in the 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. Adverse features of the patient and disease: old age, decrease or loss of consciousness, sudden agitation, extremely severe or terminal conditions, mental disability; simulation or dissimulation by the patient and underestimation (anosognosia) or hyperbolization (agravation) of the severity of the disease by the patient. , 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 course of its course, the early and late stages of the pathological process, as well as the accompanying symptoms of background and concomitant diseases, as well as various complications.

3.1.2. Unfavorable conditions: poor lighting, heating, ventilation, lack of the necessary equipment, instruments, medicines, reagents, dressings; unsatisfactory work of the laboratory, lack of consultants, means of communication and transport; absence, inaccuracy and incorrectness of information from the medical staff 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 early diagnosis; lack of effectiveness of available treatments; limited capabilities of diagnostic and therapeutic equipment.

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

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

1. Motivated diagnosis;

2. Features of the patient and disease;

3. Online access and the planned operation;

4. Technique and means of pain relief;

5. Informed consent of the patient or his proxies to carry out an operation or other instrumental intervention, recorded in the medical history and signed by the patient, attending physician, 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 the head of the department. Clinical analyzes of patients scheduled for surgery, etc.

7. When identifying indications for emergency surgery for a patient with acute surgical organ disease abdominal cavity proper preoperative preparation must certainly be carried out, the composition, volume and duration of which depend on the specific circumstances. In diseases such as severe acute pancreatitis or peritonitis, diagnostic measures 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 imperfection of scientific knowledge, which is especially important in such complex multicomponent pathological processes, such as 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 observance or violation of the norms of modern medical science, well-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 much more information that is important for successful treatment acute surgical diseases in general and acute pancreatitis, in particular.

Given the importance of careful, 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 with different forms "acute abdomen" is the most important stage of their recognition, despite the use of methods of ultrasound, computed tomography and endoscopic diagnostics. Only it can give an accurate idea of \u200b\u200bthe pathological process in all the variety of its manifestations. With the most complex pathology, the category of which, due to the variety of variants and the 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 intervention and outcome so strongly dependent on the quality of intraoperative revision. A full-fledged diagnosis during the operation requires the surgeon to both thoroughly identify the morphological signs of the disease in all anatomical formations, and adequately interpret the data. These aspects of intraoperative diagnosis in acute pancreatitis are associated with additional difficulties due to:

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

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

3.2.1. Objectives and sequence of the survey

The task of intraoperative diagnostics in acute pancreatitis is to clarify the morphological and clinical form and the prevalence of the disease for the selection of adequate techniques and the volume of surgery. 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 a lesion of the corresponding organ, with destructive pancreatitis, pronounced pathological changes are also noted in the retroperitoneal tissue, omental bursa, peritoneum, omentum and omentum and in other anatomical structures. Such components of local pathological reactions as parapancreatitis, paracolitis and paranephritis, peritonitis and omentobursitis, omentitis, ligamentitis in combination with concomitant acute pathology of the biliary tract, as a rule, are the main potential targets surgical interventions... If in acute appendicitis the diagnosis unambiguously determines the nature of the operation, then in acute pancreatitis, in order to resolve the issue of the technique of the operation and its volume, additional information is needed on the severity of all components of the pathological process. Therefore, an intraoperative examination of the abdominal cavity in acute pancreatitis should include an examination of all the above formations, and the identified components of local pathological reactions are subject to detailed and accurate reflection in the postoperative diagnosis.

The starting point for intraoperative revision is the preoperative diagnosis, which must be confirmed or rejected by identifying or excluding another 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 a passing examination of the subphrenic spaces, retroperitoneal tissue, intestinal loops and small pelvis.

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

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

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

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

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

• exclude other forms of "acute abdomen";
• to identify the characteristic morphological signs of acute pancreatitis;
• determine the form of damage to the pancreas and retroperitoneal tissue;
• to establish the prevalence of damage to the pancreas and retroperitoneal tissue;
• to evaluate the color, volume, places of accumulation of peritoneal pancreatogenic exudate;
• to evaluate pancreatogenic damage to other organs and tissues;
• subject the organs of the biliary system to a sparing revision.

3.2.2. Possible errors in intraoperative diagnosis of severe acute pancreatitis

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

The least traumatic is the approximate assessment of the state of the pancreas by examination and palpation of tissues at the “root” of the mesentery of the transverse colon. Directly adjacent to it is parapancreatic tissue along the front surface of the head, the lower edge of the body and tail. Of the pancreatic sections, the head is the most accessible for examination through the mesocolon. In severe acute pancreatitis, intraoperative revision of the mesenteric root can lead to its perforation 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 with intraoperative revision.

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

The lower surfaces of the body and tail are examined after dissecting their parietal peritoneum along the lower edge. 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 grounds is unacceptable.

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

During surgery for severe acute pancreatitis, it is possible intraoperative diagnostic error, as a result of which the surgeon has an exaggerated idea of \u200b\u200bthe severity of morphological changes in the pancreas. This error is associated with the little-known to doctors effects of "light filter" and "deceptive curtain", first described by researchers from Romania (Leger L., Chiche B. and Louvel A.) in 1981. These authors noted that in the pathological examination of the pancreatic preparations resected by them, the prevalence and depth of necrosis turned out to be significantly less than the surgeon expected.

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

Another erroneous judgment about the volume of hemorrhagic pancreatic necrosis arose as a result of the fact that lymph flowing from the pancreas accumulates in the superficial lymphatic plexus, 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 lesion of the pancreatic parenchyma as “total hemorrhagic necrosis. Only during the dissection or examination of the resected specimen was it found that under a 5-7 mm layer of slate-black necrotic parenchyma, light-yellow tissue of slightly altered pancreas was found. This allows us to qualify the data of intraoperative research as diagnostic error in intraoperative diagnosis.

The previously practiced opening of the anterior peritoneum made it possible to drain the exudate, which caused a false impression about the nature of the lesion of the pancreas. Insufficient awareness of the operator may lead to the assumption of the development of "total" pancreatic necrosis, because a layer of brown effusion in the anterior subcapsular tissue and the subsequent change in the color of adipose tissue from red to brown and black, create an erroneous impression of "total hemorrhagic necrosis". Currently, early disclosure of tissue along the lower contour of the pancreas is not recommended, because promotes excessive trauma and opens the gate wider for the penetration of pathogenic intestinal flora into it.

From the modern point of view, digital or instrumental revision of the omental bursa before the development of infected parapancreatonecrosis is not shown and is recognized as erroneous.

Pathological changes in various parts of the pancreas may not coincide. Therefore, in order to establish the correct operational diagnosis, if it is extremely necessary, the head and 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 the layer of necrotic peritoneum and anterior subcapsular tissue, the defeat of the pancreas can be much less horrific, as is often mistakenly assumed.

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

3.2.3. Diagnostic errors in severe acute pancreatitis

Analysis of 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 deceased, and in 26% of cases their importance in the onset of the patient's death was very high. Elimination of only the most gross errors would reduce the mortality from this disease.

An analysis of the case histories of patients with severe acute pancreatitis showed that in some cases this disease may not be diagnosed or misinterpreted, proceeding unrecognized under the "clinical masks" of various diseases, both abdominal and extra-abdominal.

The clinical symptoms of necrotizing pancreatitis are often atypical.
We have established that some forms of acute pancreatitis are quite characteristic of "clinical masks" of other forms of acute inflammatory diseases of the abdominal organs.

In this edition, devoted to the various options and nuances of the clinical picture of acute pancreatitis, we considered it appropriate to include an analysis of such cases. A similar study in acute appendicitis was carried out by I.L. Rotkov (1988). In the materials of this author, the "clinical masks" of acute appendicitis were analyzed, proceeding "under the flag" of other forms of OCD, including acute pancreatitis. Such comparisons have not been previously performed in acute pancreatitis.

Reviewing the case histories of the deceased 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 created by us, during the study of which 581 cases were identified, the symptoms of which were of a certain topographic and organ specificity, which is 64.6% of all studied lethal outcomes. Moreover, alternating sequences of different clinical images were often noted, which could reasonably be called "Theater of clinical masks of pancreatic necrosis"... This is not an empty play on words, because polymorphism clinical manifestations pancreatic necrosis is actually fraught with diagnostic errors and, therefore, leads to an increase in the number of deaths.

Combinations of variants of “atypical” symptomatology were often revealed.