Medical Errors

Medical errors, a category of honest mistakes made by physicians in their judgments and actions when performing various special medical duties. The absence of elements of crime in these judgments and actions—such as obvious carelessness, inattention, negligence, or evident ignorance, as well as formally incorrect or illegal aspects—allows for distinguishing the concept of medical errors from medical crimes, for which a physician bears responsibility either in a disciplinary or general criminal order; thus, as such, a physician does not formally bear responsibility for medical errors. The distinction between medical errors and criminal actions is not always an easy task and leads to a significant number of misunderstandings, both in terms of the physician's personal severe experiences up to and including suicide, and in terms of the initiation of insufficiently justified prosecutions against them by judicial authorities, especially at the initiative of the victims' relatives. A physician's crimes by negligence are often difficult to distinguish from medical errors due to ignorance, and the latter is even more difficult to distinguish from ignorance, all the more so since a physician cannot be an encyclopedist in all areas of medical knowledge, not to mention that there can be no 'norm' of knowledge in general. The concept of 'negligence' is equally unclear: for example, it is difficult to qualify the action of a surgeon who, perhaps with insufficient indications, decides on a heavy operation that leads to the death of the patient. This operation, had it been successful, could have saved the patient—and would have sparked discussions about courage, initiative, creativity, just as after a failed operation, one might speak of negligence, recklessness, etc. If, during a complex abdominal operation with an abundance of instruments, linen, tampons, and especially when necessary (for example, in clinical life) simultaneously to lecture or read about what is happening, the surgeon 'forgets' a certain instrument in the abdominal cavity, it is not so easy to determine whether this is carelessness, inattention, or simply an 'unfortunate accident' that can happen to any specialist performing work that requires great nervous tension and technical skill. The very fact that such unfortunate accidents occur among the leading representatives of surgery speaks to the fact that the decision on qualifying the physician's action is not so simple. It would probably be more correct to treat such unfortunate accidents as medical errors, which, of course, does not exclude the possibility of a more precise analysis and different qualification of these errors in individual cases. Furthermore, there exists a significant category of accidents that cannot be considered as medical errors, since they represent truly unfortunate accidents; these include, for example, cases of death during chloroforming, vaccination, encephalography, during various intravenous infusions, etc. To foresee such a possibility, in particular, for example, the phenomena of idiosyncrasy (see), even a very experienced physician is unable, since many seemingly completely harmless therapeutic and diagnostic methods and means and almost all surgical methods contain some danger of still unforeseen complications and even death. Finally, a physician, like any worker, depending on the completeness of their education, personal qualities, and even certain stages and experiences in their personal life, has the right to a certain 'defect' in their work, all the more so since in medicine the elements of science are still to a significant degree connected with elements of intuition and art. All medical errors can be divided according to their origin into objective and subjective. The first and most important objective factor should be considered the imperfection of our practical and theoretical knowledge, which, in their very nature, cannot be absolutely accurate. All actions of a physician, insofar as he strives to make them rationally scientific, are based on a series of theoretical premises; these latter are continuously changing, often contradicting one another, and often completely fall away as erroneous. Until recently, dysentery was viewed as bloody diarrhea; now the opinion is taking hold that pathophysiologically dysentery is a spastic constipation. In the middle and end of the 19th century, physicians fought against the temperature reaction first with the help of emetics, and then with antipyretic agents; at present these views have essentially changed. The fluctuations in views on kidney diseases, blood diseases, etc., are well known. Thus, the discovery of fundamental medical errors often falls only to subsequent generations. So, in the foundation of medical errors often lie errors in medical science itself. On the other hand, if a physician sees in medicine, predominantly, an art and does not pay proper attention to the scientific achievements of medicine, he may incur accusations of 'not using all possibilities' dictated by the theory and practice of his time; here medical errors grow into a crime. If, however, a physician wants to be modern and bases his actions only on fresh scientific data, seemingly logically correct, confirmed by experiment, he is also not protected from errors, sometimes very serious in their consequences: the world event—the discovery of the tuberculosis bacillus—led to the somewhat hasty use of tuberculin and a considerable number of victims of this haste. There are also many reverse cases, when practically useful actions of a physician lead to erroneous theoretical conclusions. In medicine there exists a large number of theories that have not found reflection in practice, and conversely—many practically beneficial measures that do not have correct theoretical justification (for example, feeding with raw liver in malignant anemia, treating progressive paralysis with malaria), and the treatment of malaria with quinine, as well as the treatment of syphilis with salvarsan, is also not sufficiently theoretically motivated, since the postulated theoretical dependence of the therapeutic effect of these agents on their parasitotropism is at least not proven. In practical medicine there still exists a significant empiricism with its inevitable errors; the often applied principle of treatment ex juvantibus, ex nocentibus speaks to the same. The second thing that objectively increases the number of medical errors (both practical and theoretical) is excessive and increasingly growing medical specialization and the necessity of constant consultations, often not actually realized; in the conditions of rural medicine this factor has special importance. Third—the large number of patients per physician, shortcomings in general and special equipment (X-ray, laboratories), lack of literature, etc.; fourth—the objective difficulty of examination or diagnosis (for example, in an unconscious state, absence of anamnestic data, etc.); finally, fifth (which is also to a large extent a subjective circumstance)—the lack of proper academic preparation in the physician; one cannot yet say that higher education provides all conditions and guarantees that the physician it graduates is prepared in all respects and that their calling to medical activity is fully revealed. Medical errors of subjective origin. 1. Insufficient examination of the patient, for example, incompleteness of external or internal examination, laboratory examination, etc. 2. Lack of general and special knowledge (this same lack of knowledge often lies at the basis of insufficient examination); sometimes lack of knowledge is the result of early specialization of the physician, for example, while still a student. 3. Carelessness or lightness of judgment, as well as carelessness in formulating conclusions, which has particular importance in the practice of forensic medical experts, in prognostic conclusions, in giving answers in laboratory examinations, in particular, on biopsy material. This should also include insufficient thoughtfulness of certain actions, excessive boldness of them, for example, in prescribing large doses of medications, performing very complex and heavy operations with questionable indications, etc. On the other hand, medical errors may have the opposite phenomenon as their source—lack of initiative, confusion, excessive caution. 4. Absence of qualities necessary to be a good physician, poverty of intuition, and conversely, ignoring questions of scientific medicine, in particular its technical achievements, desire to use exclusively the sphere of medical art. 5. Overestimation or incorrect evaluation of laboratory data, for example, Wassermann reaction, Widal reaction, etc. This overestimation is observed especially often at present simultaneously with the decline of medical art and the shifting of the center of gravity in the physician's activity to the so-called objective research methods. Finally, sixth, but not last place in the origin of medical errors is the physician's lack of habit of systematically controlling their diagnoses by autopsies.

The most important place among medical errors is occupied by diagnostic errors; from them depend, mainly, and subsequent errors of prognostic and therapeutic, surgical and other nature. Highly qualified clinical practice, armed with excellent laboratories, X-ray and other installations, under the best possible objective conditions still gives 15-16% fundamentally incorrect diagnoses and, in addition, about 14% inaccurate diagnoses of the main suffering (I. Davydovsky). As for complications and concomitant (accompanying) ailments, in very rare cases is there their complete recognition. Under the conditions of urban medicine (capitals) the indicated percentages somewhat increase (up to 20-25%); one can think that under the conditions of work of a rural doctor, with lesser qualification and with greater workload, the number of errors is even greater. Diagnostic medical errors are least frequent in the area of cardiovascular diseases, most frequent in diseases of the digestive tract and its glands, as well as respiratory organs. A significant number of errors falls on the recognition of diseases of organs located in the right upper quadrant of the abdomen. Many medical errors in diagnosis have their source in the confusion of the main ailment with its symptoms, especially with the bright expressiveness of the latter (for example, the incorrect diagnosis 'apoplexy' instead of arteriosclerosis of the brain with apoplexy or peritonitis instead of appendicitis with peritonitis, etc.).