A medical error in medical practice is a non-malicious act. However, this definition often refers to the negligent and unfair actions of a doctor in the performance of professional duties. And in such circumstances, medical error becomes a criminal offense, and the doctor is held accountable.

The concept and statistics of medical errors in Russia

First of all, the victim should understand that the law will be on his side, since a medical error is a criminal offense. However, it has a number of features, many of which you need to know:

• Since this mistake often happens by accident and implies an act without bad intentions, the responsibility on the part of the doctor is mitigated. For the penalty to be severe, it will need to be proven that the error was malicious.
• The objective reasons for a medical error are negligence, inattention and lack of experience. They are taken into account for the commutation of the sentence.
• Subjective reasons for a medical error are negligence in examining and carrying out medical actions, neglect of modern medical devices, etc. Subjective reasons are used in legal practice to aggravate a sentence.

According to the statement of the representative of the Investigative Committee of the Russian Federation, the latest statistics on medical errors are as follows:

• In 2015, 712 people, including 317 children, suffered from medical errors and poor quality medical care.
• In 2016, 352 patients died due to medical errors, of which 142 were children. At the same time, the UK received more than 2,500 reports of crimes related to medical negligence. On their basis, more than 400 criminal cases were opened.

There is no precise definition of medical error established to date. That is why in the proceedings, the situation is quite difficult, because it is required to prove the very fact of a medical error.

Classification of medical errors

Today, medical errors are classified according to different principles, the main one of which is at what stage of the implementation of medical care and in which field of activity the medical error occurred. Let's look at it further:

• Diagnostic... These kinds of errors occur at the diagnostic stage and are the most common.
• Organizational... They happen with insufficient or illiterate organization of medical care, as well as with insufficient provision of medical services.
• Treatment-tactical... Typically occur after diagnostic. That is, the specialist makes a mistake in the diagnosis and begins to treat the patient in accordance with a specific diagnosis.
• Deontological... They relate to the psychological nature and behavior of the doctor when communicating with employees, patients and patients' relatives.
• Technical... Often related to paperwork. This may be an incorrectly filled out patient record, an extract, any medical documentation, etc.
• Pharmaceutical... There are situations where the pharmacist has incorrectly identified indications or contraindications, as well as compatibility with other drugs.

Medical errors are not uncommon today. As a result, there are already considerable statistics with various situations in which medical errors appeared. In the following video, let's take a look at 10 of the most horrifying examples of medical errors:

Errors that cannot be classified in any way are classified as "other". Responsibility for it will depend on what type the error is assigned to.

Medical errors in dentistry

Errors made in dentistry are now considered a serious topic of controversy. The fact is that dental services are quite expensive, so patients have a selfish goal in filing claims. According to statistics, now about 30% of claims brought against dentists do not have a really good reason. Nevertheless, dentists make mistakes in treatment - it can be a wrong diagnosis, an unsuitable means for anesthesia, preservation of a tooth to be removed, etc.

In order to avoid problems in the future when dealing with a client, the specialist should clearly and clearly explain the treatment regimen in advance, consult with the patient, and clarify any little things with him. Sometimes in dental clinics, especially with serious treatment, a contract is concluded, which states that the patient knows about the prescribed treatment and has nothing against him.

Types of liability for medical error

If a medical error is detected on the internal line, the punishment will be presented in the form of reprimands, deprivation of a category, sending to advanced training courses, etc. Perhaps a mistake will lead to a transfer from one place of work to another, for example, from the position of a resident of the surgical department to the position of a surgeon in a polyclinic.

If an error is discovered during an external investigation, responsibility in this case can be conditionally divided into two types, which we will consider further:

• Civil liability... As a rule, it implies monetary compensation for damage, which includes moral damage, the patient's money spent on the service, the cost of the required care, the cost of additional services, etc. Note that there is no clear algorithm for establishing the amount of money that the plaintiff may require. Therefore, he has the right to present the amount he needs himself, but within reasonable limits.
• Criminal liability... Established for harm caused to life and death due to medical error. In the event that the patient received poor-quality medical care, but no significant harm was caused to his health, criminal liability is impossible. To determine the extent of the damage, a forensic medical examination is carried out.

Often, victims have to make certain efforts to receive moral harm, because usually doctors do not agree to admit the fact of a mistake and by all means prove their innocence.

Articles of the Criminal Code of the Russian Federation on medical errors and criminal liability

The Criminal Code of the Russian Federation does not have a separate article that provides for liability for medical errors, however, a special part provides for punishment for certain elements of a crime, as a result of which irreparable harm was caused to human health or the patient's death followed.

So, if as a result of the examination it is established that the patient died due to a medical error, according to Part 2 of Art. 109 of the Criminal Code, a doctor can be imprisoned for up to 3 years. If serious harm was caused to health, the perpetrator is sentenced to a term of up to 1 year. It should be noted that both in the first case and in the second, the deprivation of the right to engage in medical activities may also be provided.

Criminal liability will also follow the following elements of a crime:

• An unlawful abortion was carried out, and the patient died or suffered serious harm to her health. Part 3 of Art. 123 of the Criminal Code.
• The patient contracted HIV due to the negligence of the doctor. Part 4 of Art. 122 of the Criminal Code provides for imprisonment for up to 5 years.
• If, as a result of illegally carried out medical or pharmaceutical activities, the patient has received serious harm to health, the perpetrator is punishable by Part 1 of Art. 235 of the Criminal Code. Fatal cases are considered part 2 of Art. 235 of the Criminal Code.
• If the patient was not provided with assistance, as a result of which he received harm of moderate or light severity, the punishment is established by Art. 124 of the Criminal Code. If the harm is more significant or irreparable, then Part 2 of Art. 124 of the Criminal Code.
• If the fact of medical negligence is established, the result of which is the infliction of serious harm to human health or the death of a patient, then Part 2 of Art. 293 of the Criminal Code.

After the initiation of a criminal case pending a judicial investigation, the victim may file a civil action to obtain monetary compensation for the damage caused. This right is enshrined in Art. 44 of the Criminal Procedure Code.

Where to go in case of medical error?

Consider the options where you can go in case of a medical error:

• Managers of a medical institution... This can be the head of the department / clinic / hospital or the head physician. He needs to tell in detail about the situation and provide evidence that the fact of treatment and medical error really happened. Sometimes issues can be settled already at this stage. The responsibility of a doctor who made a mistake can be in the form of a loss of a bonus, a deduction from salary, a reprimand, or a fine.
• Insurance company from which you obtained your insurance policy... Here, the patient will need to present all the evidence that he has, as well as explain in detail the current situation. Insurance officers will have to review your case and conduct a detailed examination of the actions taken by the doctor. Based on the results of the examination, a fine will be imposed on the medical institution where the medical error was made.
• Judicial authorities... It will be necessary to bring to the court not only all paper evidence, but also a claim in which you write in detail your requirements against the defendant. In court, the case will be carefully considered. This will most likely require attending a series of legal proceedings, which will most likely result in the receipt of the required compensation.
• Prosecutor's office... You can contact here if you want to initiate a criminal case against a person who has committed a medical error. Be prepared for lengthy proceedings and serious consequences if the evidence provided is found to be false.

In any case, you should not be afraid to defend your rights. In this case, it will not be difficult to prove your case if all documents can be saved. The law is on the patient's side.

How to prove a medical error?

To prove a medical error, first of all, it is necessary to keep all documents confirming the fact that the medical institution has provided medical services. These documents may include:

• medical card with relevant records;
• documents with test results;
• copies of papers with the results of examinations;
• checks and receipts of payment for services rendered;
• receipts and receipts for the purchase of prescribed medications.

It is also good if you have witnesses who are willing to confirm the medical error. The collected evidence is recommended to be photocopied and certified. It is best to provide certified copies to the court or prosecutor's office, and leave the originals in your hands in case you still need them.

Ministry of Health of the Russian Federation

State educational institution

Chita State Medical Academy

Department of Forensic Medicine

LEGAL AND DEONTOLOGICAL ASSESSMENT OF MEDICAL ERRORS AND ACCIDENTS IN MEDICINE, LEGAL AND SCIENTIFIC-PRACTICAL SIGNIFICANCE OF MEDICAL DOCUMENTATION.

Edited by the Head of the Department of Forensic Medicine

Doctor of Medical Sciences, Professor Avkhodiev G.I.

Approved and approved by the CMK GOU CHGMA.

PURPOSE OF THE LESSON:

To acquaint students with the legal aspects of medical errors and professional crimes. Give the concepts of "medical error", "professional offense", "medical accident". Show the role of medical documentation on specific examples from practice in the criminal process.

Bring the appointment of clinical and anatomical conferences and their deontological signs. To highlight the articles of the Criminal Code concerning professional offenses of medical workers.

MOTIVATIVE CHARACTERISTIC OF THE THEME.

Medical errors and medical crimes are not uncommon these days. Where is the line between error and crime, is there no place for an accident? These and other questions are most often encountered in the investigation of so-called "medical cases". Often, medical documentation is used to resolve these not simple issues - as an objective proof of the doctor's pitch or innocence. ”The importance of this problem is due to everyday practice and the specifics of medical practice, because under an hour health, and life itself, depends on the knowledge, professional training and conscientiousness of medical workers.

EQUIPMENT OF THE LESSON.

2. Lecture material.

3. Educational case histories

4. Criminal Code

Test questions to determine the initial level of knowledge

1. Give a definition of the term "medical error"?

2. Classification of medical errors?

3. Medical error as a deontological concept?

4. Does honey. the employee's right to make mistakes?

5. Diagnostic errors and their causes?

6. Errors in the choice of treatment methods. The line between error and crime?

7. Errors in the organization of medical care, the reasons for this category of errors?

8. Errors in maintaining medical records. Error, negligence or intent?

9. The role and objectives of clinical and anatomical conferences in the analysis of medical errors?

10. Deontological principles of conducting clinical and anatomical "conferences.

11. What are the main tasks of clinics about-anatomical conferences?

12. What is called an "accident" in medicine?

13. Differences between a medical error and an accident 7

14. Responsibility of medical professionals for errors and accidents?

V1. The structure of the practical lesson.

1. Organizational issues - 5 min.

2. Control survey - 25 min.

3. Independent work -120 min.

4. Problem solving - 50 min.

5. Control of the final level of knowledge - 30 min.

6. Summary. Assignment at home - 10 min.

GUIDANCE BASIS FOR STUDENTS 'ACTION IN PRACTICAL LESSONS.

1. Study of the methodological manual.

2. Analysis of specific cases from practice

3. Analysis of case histories.

LEGAL AND DEONTOLOGICAL ASSESSMENT OF MEDICAL ERRORS AND ACCIDENTS IN MEDICINE. LEGAL AND SCIENTIFIC-PRACTICAL IMPORTANCE OF MEDICAL DOCUMENTATION.

Part 1

In a very complex and responsible professional medical practice, there may be cases of adverse outcomes of medical intervention. Most often, they are determined by the severity of the disease or injury itself, the individual characteristics of the organism, late, independent of the doctor's diagnosis, and, hence, the belated start of treatment. But sometimes adverse outcomes of medical intervention are the result of an incorrect assessment of clinical symptoms or improper therapeutic actions. In these cases, we are talking about MEDICAL ERRORS.

The Big Medical Encyclopedia defines a medical error> as a doctor's mistake in the performance of his professional duties, which is the result of a conscientious delusion and does not contain corpus delicti or signs of misconduct. / Davydovskiy IV et al., "Medical errors" BME-ML976. vol. 4. 442-444 /.

Consequently, the main content of the concept of "medical error" is the DOCTOR'S FAITHFUL DELUSION in his judgments and actions. This means that in a particular case, the doctor is convinced that he is right. At the same time, he does what is required, does it in good faith. And yet he is mistaken. Why? Distinguish between objective and subjective causes of medical errors

Objective reasons do not depend on the level of training and qualifications of the doctor. If they exist, a medical error can arise when the doctor uses all available opportunities to prevent it. The OBJECTIVE reasons for the appearance of medical errors include: - insufficient development of medicine itself as a science / it means insufficient knowledge of the etiology, pathogenesis, clinical course of a number of diseases /,

Objective difficulties in diagnosis / unusual course of the disease or pathological process, the presence of several competing diseases in one patient, severe unconsciousness of the patient and lack of time for examination, lack of required diagnostic equipment /.

SUBJECTIVE causes of medical errors, depending on the personality of the doctor and the degree of his professional training, include: - insufficient practical experience and the associated underestimation or overestimation of anamnestic data, results of clinical observation, laboratory and instrumental research methods, as well as a doctor's overestimation of his knowledge and opportunities.

Practice shows that experienced doctors are mistaken only in very difficult cases, and young doctors are mistaken even when the case should be considered typical.

MEDICAL ERROR - not a legal category. In the actions of a doctor that led to a medical error, there are no signs of a crime or misconduct, i.e. socially dangerous acts in the form of action or inaction that have caused significant / for a crime / or insignificant / of the day of the offense / harm to the rights and interests of a person protected by law, in particular, health and life. Therefore, a doctor cannot be held criminally or disciplined for a mistake. This fully applies only to medical errors "based on OBJECTIVE reasons. If the reasons are SUBJECTIVE, i.e. related to the personal or professional qualities of a doctor ”, before one hundred wrong actions are recognized as a MEDICAL MISTAKE, it is necessary to exclude elements of negligence and negligence, or such insufficient knowledge that may be considered medical ignorance. Defects in medical activity caused by the doctor's unscrupulous actions or his failure to fulfill his capabilities and the capabilities of a medical institution cannot be called a medical error.

All medical errors can be divided into the following groups:

Diagnostic errors;

Errors in the choice of method and treatment;

Errors in the organization of medical care,

Errors in maintaining medical records.

Some authors / N.I. Krakowski and Yu. Gritsman "Surgical errors" M. Medicine "1976 -C 19 /. propose to highlight one more type of medical errors, which they named, errors in the behavior of medical personnel. Errors of this kind are entirely deontological errors.

Speaking about the problem of medical errors in general, I.A. Kassirsky writes: “Medical errors are a serious and always urgent problem of healing. It must be admitted that no matter how well the medical work is, it is impossible to imagine a doctor who already has a great scientific and practical experience behind him, with an excellent clinical school, very attentive and serious, who in his activity could accurately determine any disease and treat it just as flawlessly, do ideal operations ... Errors are inevitable and sad costs of medical activity, errors are always bad, and the only optimal thing that follows from the tragedy of medical errors is that they teach and help in the dialectic of things, whatever they were. They carry in their essence the science of how not to make mistakes and it is not the doctor who makes a mistake that is to blame, but the one who is not free from cowardice to defend it. " / Kassirsky IA "About healing" - M- Medicine. 1970 C, - 27 /.

From the above, two important points can be distinguished. First, the recognition that medical errors are inevitable in medical practice "because they are caused not only by subjective but also by objective reasons. And secondly, each medical error must be analyzed and studied so that it itself becomes a source of prevention of other errors. In our country, a system for analyzing medical actions in general and medical errors in particular, in the form of clinical and anatomical conferences, has been developed and is being applied.

Practice shows that in a significant percentage of cases, complaints against doctors and nurses are caused, first of all, by the wrong behavior of medical personnel in relation to patients, their violation of deontological norms and rules.

Let us analyze the groups of medical errors noted above.

DIAGNOSTIC ERRORS.

Diagnostic errors are the most common. Formation of a clinical diagnosis is a very complex and multicomponent task, the solution of which is based, on the one hand, on the doctor's knowledge of the etiology, pathogenesis, clinical and pathomorphological manifestations of diseases and pathological processes, on the other hand, taking into account the individual characteristics of their course in this particular patient. The most common cause of diagnostic errors is OBJECTIVE difficulties, and sometimes the impossibility of early diagnosis of the disease.

Many painful processes have a long course with a significant latency period, and practically, asymptomatic course. This applies to malignant neoplasms, chronic poisoning, etc.

Great diagnostic difficulties arise in the lightning-fast course of diseases. As indicated, the objective causes of medical errors can be an atypical course of the disease or combined competing diseases, a serious condition of the patient with insufficient time for examination. Alcohol intoxication of the patient significantly complicates the diagnosis, "which can mask or distort the symptoms of a disease or injury.

The reasons for diagnostic errors can be underestimation or overestimation of anamnestic data, patient complaints, results of laboratory and instrumental research methods. However, these reasons cannot be regarded as objective, because they run up against a lack of qualifications and experience of the doctor.

Here are some examples of diagnostic errors:

A 10-year-old boy developed abdominal pain, nausea, repeated vomiting, and loose watery stools. The next day, an admixture of mucus appeared in the feces, the body temperature rose to 38 degrees. The parents and the boy associated the onset of the disease with eating in the canteen. The child was hospitalized two days later. Complained of diffuse abdominal pain. On examination, it was noted that the abdomen was somewhat tense and painful in all parts. There are no signs of peritoneal irritation. After stool, the abdomen became softer, the pains were localized along the ascending and descending parts of the intestine. In the blood leukocytosis / 16 500 / ESR - 155 mm / hour. Diagnosed with acute gastroenteritis. Conservative treatment was prescribed. In the future, the boy's condition did not improve. On the third day of inpatient treatment, the boy was examined by a surgeon. which ruled out acute surgical diseases. However, the next day he offered to transfer the boy to the surgical department. The child's condition worsened, signs of peritonitis appeared. A laparotomy was performed. Liquid pus was found in the abdominal cavity. The source of peritonitis was a gangrenous altered appendix located in the pelvic cavity. in the infiltrate between the cecum and the sigmoid colon. The boy was not saved. According to the conclusion of the forensic medical expert commission, the reason for the late diagnosis of appendicitis was its atypical course, due to the unusual location of the appendix in the pelvic cavity.

In another case, in a 76-year-old woman, phlegmonous appendicitis with infiltration of surrounding tissues was mistaken for a cancerous tumor of the cecum. This was largely facilitated by the atypical, subacute course of the disease, repeated vomiting, the patient's weight loss, the absence of characteristic symptoms of irritation of the peritoneum, in the presence of a clearly defined palpation tumor-like formation in the right iliac region and the phenomena of intestinal obstruction. The woman was operated on twice. The first operation is palliative "formation of an ileostomy". The second radical is colon resection. The correct diagnosis was made after examining the biopsy material and on the basis of the data from the sectional material, because the patient died as a result of sepsis, which was a complication of a highly traumatic operation.

This example is provided as an illustration of a diagnostic error. However, with a more serious approach, a violation of the current instructions can be found here - in particular, the patient could not be taken for surgery without biopsy data from aphids. the patient's condition made it possible not to take her to the operating table on an emergency basis. That is, in this case, one could talk about a medical crime that took place. The category of misconduct is not suitable because the diagnostic error led to a grave consequence - death.

ERRORS IN THE CHOICE OF METHOD AND CONDUCT OF TREATMENT

These errors are several times less common than diagnostic errors. In some cases, they are caused by incorrect or delayed diagnosis. But even with a correct and timely diagnosis, errors in treatment may occur / for example, the wrong choice of treatment method in the presence of several possible or the wrong choice of the method and volume of surgical intervention A. It may happen that with the timely start of treatment and the correct choice of the method, errors in technique are made ... This applies primarily to surgical operations. Consider an example of errors in the appointment and implementation of treatment:

A 63-year-old man was admitted to a urological hospital with acute urinary retention for 8 hours and gross hematuria that appeared during this period. The condition at the time of admission is satisfactory. HELL 130 and 80 mm Hg Art. An urgent cystoscopy revealed a bleeding tumor of E x 4 cm on the posterior wall of the bladder.A week later, a filling defect and a neoplasm of 1 x 1 cm were detected on the cystogram. Based on these data, a diagnosis of cancer of the posterior wall of the bladder complicated by bleeding was established. However, during the operation, the neoplasm was not found.

The postoperative period was complicated by pyelonephritis with generalization of the infection, which led the patient to death.

A forensic medical examination was carried out based on the materials of checking the complaints of relatives about improper treatment. In conclusion, the expert committee indicated that the erroneous diagnosis of bladder cancer was due to an incomplete examination of the patient. Single cystoscopy and cystography, in the presence of some discrepancies in the data, are not enough to diagnose a disease such as bladder cancer. For a tumor, apparently, were taken blood clots adhering to the mucous membrane of the bladder. The wrong diagnosis, in this case, led to the wrong choice of treatment method, in particular, surgery, which the patient did not need.

In another case, a 24-year-old woman experienced a perforation of the uterine wall during a medical abortion, complicated by a parametrium hematoma with subsequent suppuration.In this regard, an operation was performed - supravaginal amputation of the uterus, with the removal of the inflamed right fallopian gross and drainage of the abdominal cavity. The woman died 1 month later as a result of developing sepsis. When analyzing this case, the expert commission noted that the operation of the woman was not performed in full. The presence of a suppurative parametric hematoma required a more radical operation: - extirpation of the uterus with subsequent drainage of not only the abdominal cavity, but also the parametrium. This would facilitate the outflow of pus from the parametrium and, possibly, prevent the generalization of infections.

ERRORS IN THE ORGANIZATION OF MEDICAL CARE

The very designation of these errors indicates that their occurrence is associated with an incorrect or insufficiently thought-out organization of medical care. The reason for such errors is either the insufficiently high professional level of the heads of individual health care units, or the unfavorable conditions created for the work of a certain medical and prophylactic institution. As a result of errors in the organization of treatment and prophylactic care, the very matter in the provision of medical care and patients suffer, despite the fact that doctors of medical institutions, through the fault of the leaders of which errors occur, can quite conscientiously fulfill their duties.

It is possible to point out some of the conditions under which errors may occur in the organization of medical care. If the theater, as they say, begins with a coat rack, then the work of a medical institution begins with the admission department. The timeliness of the provision of honey largely depends on the state of this work. help especially in urgent cases, with diseases, injuries and poisoning, requiring urgent action. Therefore, the work of the admissions department must be carefully thought out and organized. She requires close attention to herself from the head of the institution. In the activities of the staff of the admission department, rudeness and indifference are not permissible, which have an extremely negative effect on the patient, causing a negative attitude towards the medical institution and its personnel. This, ultimately, negatively affects the results of treatment, as happened in the next case. Citizen K., 65 years old, after eating mushrooms and canned food, felt pains in her stomach on the left. She connected the pain with food intake and applied to the Central Regional Hospital. The paramedic did not examine her and sent her to the clinic. The time was late and the clinic was no longer working. The woman again returned to the emergency room of the hospital, but the paramedic again did not examine her, and when asked to call the doctor on duty, he replied that he was busy with a serious patient and advised to go to the clinic in the morning. In the morning, the woman was taken by ambulance to the same emergency room. After examination by the doctor on duty, the diagnosis was made - strangulated inguinal hernia. The patient was taken for an operation. During the operation, it turned out that the patient developed peritonitis. After 6 days, the patient died from diffuse purulent peritonitis.

In this example, organizational mistakes of medical personnel are clearly visible, which ultimately led to a late diagnosis and a late start of treatment, which affected the outcome of the disease.

In another case, citizen S. was brought by an ambulance with a gunshot wound to his chest 45 minutes after the injury. The ambulance doctor diagnosed a gunshot wound penetrating into the chest cavity, complicated by hemothorax. However, the surgeon on duty was busy with the operation and therefore was only able to get out to the wounded after 4 hours. During this time, the patient's condition progressively worsened. And when the wounded man was taken to the operation, they had to carry out resuscitation measures, "which were unsuccessful. When analyzing this case, it was found that the paramedic on duty, in violation of the internal order, did not notify the chief physician that there was a serious patient in the emergency room who needed an urgent operation. And as a result - the death of the patient.

Both examples clearly demonstrate the heartless attitude of the medical emergency staff on duty. Lack of necessary educational work in these departments, unclear organization of their work.

One of the sources of errors is the ill-conceived work of branches on weekends and holidays, in the evenings and at night. This can affect both patients who are already being treated and those who are newly admitted, especially those who need urgent help.

So in one of the hospitals, a 14-year-old girl was treated. She was operated on for appendicitis. But within 4 days after the operation, the girl had a temperature of 37.3 -37.7 degrees C. On the 5th day there was a day off. The girl was examined by the doctor on duty / the examination was superficial / who, at the insistence of the mother, discharged them home. Already in the morning the girl was admitted to the hospital again in a serious condition with a temperature of 39 degrees. C. After examination, she was taken for a second operation. It was revealed that the girl developed a postoperative bowel cult infiltration. In the postoperative period, purulent peritonitis developed and the girl died on the 6th day. When analyzing this case, it was established that the day hospital does not have developed internal regulations and there is no provision on the rights and obligations of the personnel on duty. In this case, the doctor on duty did not have the right to write out the patient on the day off, all the more, without coordinating this issue with either the attending physician or the head. branch.

Errors in the organization of medical care can also be caused by the incorrect distribution of the bed fund. Thus, some departments can work with underload, while others with overload, which leads to a significant deterioration in the quality of treatment. A similar situation can arise in the case of the forced turning out of excess beds,

Insufficiently thought-out organization of work on the supply of medical institutions with devices, reagents, medicines, dressings, etc. can also cause defects in diagnosis and treatment.

ERRORS IN THE MAINTENANCE OF MEDICAL DOCUMENTATION

These errors can lead to wrong conclusions in the diagnosis of diseases, to wrong decisions of VTEK, to insufficiently substantiated rehabilitation measures. Next, we will dwell in detail on the requirements for the preparation of medical documentation.

Analysis of all types of medical errors plays an important role in their prevention, in improving the qualifications of doctors. This analysis is carried out mainly at clinical and anatomical conferences, which have become an obligatory and good tradition in our clinics. They were first introduced into practice by the prominent pathologists I.V. Davydovsky in 1930, and since 1935 the styles are mandatory for all medical institutions.

In Appendix No. 7 to the order of the Ministry of Health of the USSR of April 4, 1983 No. 375, the main tasks of clinical and anatomical conferences are formulated.

They are:

Improving the qualifications of doctors of medical institutions and improving the quality of clinical diagnostics and treatment of patients through joint discussion and analysis of clinical and sectional data.

Identification of causes and sources of errors in diagnosis and treatment at all stages of medical care, timeliness of hospitalization. Identification of deficiencies in the work of auxiliary services / X-ray, laboratory, functional diagnostics, etc. /.

I.A. Kassirsky rightly draws attention to the observance of deontological norms in the "doctor - doctor" system during clinical and anatomical conferences "First of all, they should not turn into a pathologist's trial over a clinician. He / the pathologist / should not act either in the role of a prosecutor or in the role of a supervisor. At the same time, clinicians must strictly scientifically, objectively and self-critically acknowledge the mistakes that have occurred in the diagnosis and treatment. "

Finishing the analysis of medical errors, I would like to emphasize that since in the actions of the doctor, in such cases, there is no intent or signs of careless guilt, these errors do not carry corpus delicti or misdemeanor. Therefore, the doctor is not criminally liable for such actions. Professional and human conscience is punished for medical errors of a doctor, if they are, of course, inherent in a given person.

ACCIDENTS IN MEDICAL PRACTICE

In some cases, adverse outcomes of medical intervention can be observed with correct, timely, qualified treatment or diagnosis. These are the so-called ACCIDENTS.

ACCIDENTS in medical practice are such unsuccessful outcomes of diagnostic or therapeutic procedures or interventions in which, on the basis of modern medical science data, it was objectively impossible to foresee the negative consequences of the actions performed, and therefore it was impossible to prevent them. Unsuccessful outcomes in such situations do not depend on someone else's mistakes. They are associated with random circumstances that the doctor could not have foreseen.

Typical accidents can include: intolerance of patients with certain medications; death from fatty embolism during metal osteosynthesis operations; reflex cardiac arrest, etc.

I remember well the case when a 46-year-old patient with osteochondrosis was prescribed radon baths from the Molokovka sanatorium. The preliminary examination data, including the ECG, did not reveal any contraindications. At the very first bath session, the patient died from acute coronary insufficiency. The nurse on duty in the procedural room did not even notice the death of the patient, although she was always at the workplace.

And there are a lot of such examples. Fortunately, not all of them end in a sad outcome. But there are a lot of such unforeseen situations in the activity of doctors of any profile, and the doctor should always be ready for them.

MEDICAL, SCIENTIFIC-PRACTICAL AND EDUCATIONAL IMPORTANCE OF MEDICAL DOCUMENTATION

Medical documentation is a system of accounting and reporting documents. intended for the recording and analysis of persons and groups of the population receiving medical care, the volume and quality of the care provided, as well as the activities of medical and preventive institutions,

Medical documentation includes primary registration documents / inpatient card, individual outpatient card, disability certificate, child development history / and reporting documents / preventive vaccination card, clinic exchange card, emergency notification, etc. /.

The forms of medical documents are the same for the whole country and are put into effect by the Ministry of Health with the assignment of a number.

The primary registration document is a card of an inpatient and outpatient patient. It is designed to record the patient's health status during the treatment period and diagnose his disease.

It is a system of records documenting the results of diagnostic tests and the san diagnosis; therapeutic measures, course and outcome of the disease. The history of the disease is the basis for further, after discharge from the hospital, medical actions, to address the issues of rehabilitation of the patient, his work.

If the disease ends in death, then the data of the pathological or forensic examination of the corpse are entered into the history of the disease.

The scheme of the case history was first proposed by the Russian clinician, the remarkable scientist M.Ya. Mudrov / 1776 - 1831 /, who developed in detail the doctrine of the anamnesis, introduced the methods of palpation, percussion and auscultation into the clinic. The history of the disease, before acquiring a modern form, absorbed the practical recommendations of the most prominent Russian scientists, such as G.A. Zakharyin, A, A, Ostroumov, S.P. Botkin and others. They developed a scheme of scientifically based construction of schemes for clinical examination of a patient, etiopathogenetic substantiation of clinical diagnosis, and developed an integrated approach to treatment.

The form of the medical history was constantly changing. Now there is a form referred to as the "inpatient card"

The history of the disease has an important therapeutic and diagnostic, scientific, practical and legal significance.

MEDICAL AND DIAGNOSTIC value of the medical history is manifested in the fact that diagnostic and therapeutic measures are carried out according to the records in it.

Currently, both the diagnosis and treatment of a patient is often carried out not by one, but by several doctors. In these cases, the records in the medical history allow integrating the efforts of many doctors in the diagnostic process and ensure continuity in the course of the patient's treatment.

SCIENTIFIC-PRACTICAL value of the medical history lies in the fact that it is an irreplaceable source of scientific information about the causes and conditions of various diseases, their clinical course, and outcomes. Analysis of a large number of case histories makes it possible to develop recommendations for correct diagnosis, rational treatment and prevention of diseases. The forms of formalization of records on clinical manifestations of diseases, which are currently being introduced, make it possible to use modern computer methods of diagnosis, determine the degree and risk factors, indications for the use of certain methods of treatment, and predict diseases.

Correct and complete filling of the medical history helps to form clinical thinking, allows you to comprehend the information received from the patient and as a result of the patient's examination. A correct, meaningful assessment of symptoms contributes to the correct diagnosis and, consequently, the choice of treatment methods. That, ultimately, has a positive effect on the outcome of the disease as a whole.

Case histories, filled in in a particular medical institution, objectively characterize the "face", the level of medical and diagnostic work in it. The upbringing of young specialists largely depends on how the work with medical documentation in a medical institution is organized.

The case history often appears in the role of a legal document and therefore has a very important LEGAL SIGNIFICANCE.

A medical history is a medical document, and any medical document is, first of all, a legal document, since at any moment it can become the subject of a forensic investigation.

The word "Document" itself is translated into Russian as a METHOD OF PROOF. Art. 69 of the Criminal Procedure Code reads: "Evidence in a criminal case is any factual data on the basis of which, in the manner prescribed by law, the inquiry bodies, the investigator and the court establish the presence or absence of a socially dangerous act, the guilt of the person who committed this act, and other circumstances that are important for the correct resolving the case.

These data are established by the testimony of witnesses, the victim, the suspect, the EXPERT'S CONCLUSION, material evidence, protocols of investigative and judicial actions and OTHER DOCUMENTS. "

Provision of medical care to citizens of the Russian Federation is a legal obligation of medical institutions and their employees: doctors, middle-class medical workers. staff, which implements the constitutional right of patients to receive this assistance.

The history of the disease, the card of an outpatient patient records all the actions of medical workers to provide patients with diagnostic and treatment assistance. It is from the history of the disease that one can judge the necessity, timeliness, and, consequently, the correctness of all therapeutic and diagnostic measures. This is, first of all, the legal significance of the medical history.

Thus, describing a medical history and / or another honey. document / condition of the patient and the treatment prescribed for him, the doctor must always bear in mind the legal significance of the document he draws up, because the entries in it, especially in cases of injury, in the broadest interpretation of this concept, may be of significant interest to the investigation. , such records must be made taking into account the requirements for them as sources of evidence.

AND I. Mudrov once wrote: "The history of the disease should have the dignity of an accurate representation of what happened .. It must be fair. The doctor needs to write it zealously, like a painter, the slightest features and shadows depicting a person on the face."

It is clear that the more complete and objective the content of the case history, the easier it is to establish from it one or another fact of interest to the consequence.

So, in the history of the disease, the time of the patient's admission to the hospital is noted. From his words or from the words of the accompanying person, the time and place of the injury and the circumstances or conditions under which it was received are indicated. Relevant information important for the investigation of a crime may be contained in the accompanying ambulance document with which the victim is admitted to the hospital.

Perhaps the most important for the investigation of crimes against life and health are the data of the medical history related to the description of injuries. The nature of the objective changes found in the victim is the basis for the attending physician both to establish a diagnosis and to choose rational methods of treatment.

The attending physician, examining the lesions, establishes their morphological manifestations; abrasions, bruises, wounds, dislocations, fractures, etc. Analyzing the properties of damage, decides the question of their origin / from the action of a blunt or sharp object, from a firearm, etc. /. All objective data should be recorded in non-. torii of the disease. In this case, the description of the features of the damage cannot be replaced by a "diagnosis", ie. if the patient has a wound, then the doctor is obliged to describe its characteristics, for example: a wound of a linear shape, with smooth, non-precipitated edges, 1.5 cm long, one end of the wound / lower / sharp, the opposite is rounded. The wound channel leaves the wound and penetrates into the abdominal cavity. Do not replace this description with a diagnosis; "stab and cut wound". For each of the detected lesions, it is required to note its exact localization, size, morphological properties. And in case of transport injury and gunshot wounds, it is necessary to give the distance from the plantar surface of the feet to damage. The shape of the wounds should be described before and after bringing its edges together, this provision also applies to its dimensional characteristics. An important point is a careful examination, and then a description of the ends of the wounds, its bottom, the color of crusts on abrasions, a description of the phenomena of inflammation around the wounds or the absence thereof, the presence of bruises and hemorrhages in the area of ​​the wounds. One of the most common mistakes in the description of injuries is an incomplete examination of the body, when the doctor examines only the area of ​​the main injury and, at best, adjacent areas. For instance; the patient is admitted with a fracture of the lower jaw. The doctor examines him, describes the fracture of the lower jaw, but the fact that there may be abrasions, bruises, small wounds on the body "forgets" and even if he sees them, he does not describe them in the history of the disease. believes that since such damage is not subject to special treatment, then there is no need to describe it. Especially often, such cases are observed in transport injuries, when fractures are described, large, requiring surgical treatment of wounds, and everything else is not reflected in the history of the disease. But the history of the disease is sometimes the only source from which one can glean information about the number and points of application of the traumatic force ”to establish the number of blows and their localization, etc. Some of the wounds are treated surgically, some heal by secondary intention, which will not allow a full examination of the scars in the future.

In accordance with Art. 79 of the Criminal Procedure Code. to determine the nature of the injuries and determine the severity of these injuries, a forensic medical examination is mandatory. But the medical examiner rarely has the opportunity to examine the victim immediately after the injury. More often than not, this is done after a certain time, usually after a few days, when, under the influence of treatment and time, the type of damage changes. Therefore, the expert's conclusions about the nature of injuries, the mechanism of their formation, the severity and prescription of their occurrence are often based only on the data of the medical history. And naturally, the more fully and objectively the document is drawn up, the fuller and clearer the conclusions of the forensic expert will sound.A careless and inaccurate description of injuries in the medical history can lead to a situation where the forensic expert will either be forced to refuse to answer questions at all investigation, or may draw the wrong conclusions.

In the noted aspect, it is of great importance to describe in the history of the disease and preserve for transmission to the investigator FOREIGN INCLUSIONS found in wounds / bullets, wads, particles of paint, varnish, fragments of a knife blade or other tool /, as well as excised edges of wounds, in a forensic medical examination which information can be obtained that is important for establishing the characteristics of the instrument of injury and the mechanism of its action.

A significant place in the history of the disease is given to the diagnosis. Diagnosis translated from Greek means recognition and is a short medical opinion on the nature of a disease or injury, expressed in terms accepted by modern science.

The diagnosis made by the attending physician in the medical history is the result of clinical, instrumental and laboratory studies of the patient. The diagnosis must be confirmed by records of its objective confirmation / symptomatology, additional research data, etc. /. The diagnosis is not only an important link in the treatment of the patient, but also in giving an opinion by a forensic medical expert about the severity of the existing injuries, especially when determining a life-threatening condition.

It is not by chance that the scheme of the medical history provides for several columns for the preparation of the diagnosis: diagnosis of the referral institution, diagnosis upon admission, clinical diagnosis, final clinical diagnosis. This is due to the fact that the diagnosis of a disease or injury in some cases can be difficult / due to the lack of anamnesis, unconsciousness of the patient, blurred clinical picture, etc. / Completion of all fields related to the diagnosis is MANDATORY.

The final clinical diagnosis is not always true. When analyzing case histories by treatment and control commissions, pathologists or forensic experts, it is sometimes established that either the diagnosis as a whole is erroneous, or the complication of the disease or concomitant disease has not been identified. In some cases, the diagnosis is unreasonable or contains errors in its compilation and formulation / in the first place is not the underlying disease, but its complication, etc. /.

It happens that the diagnosis is made only on the basis of the patient's complaints and is not confirmed by the data of an objective study. Most often we see this when making a diagnosis: Concussion. This causes certain difficulties in deciding the severity of the damage. And it is no coincidence that the rules of forensic medical determination of the severity of bodily injury provide for the removal of such a diagnosis. But this will change the assessment of the severity of bodily injury, which is very important for the investigation. Thus, citizen S., 28 years old, who was in a state of light alcoholic intoxication, was struck with blunt objects on various parts of the body. The patient was delivered to the hospital, where he complained of headache, nausea. I didn’t lose consciousness. Upon admission, the condition is satisfactory, the smell of alcohol from the mouth. Meningeal symptoms and signs of cranial nerve pathology were absent. Hemodynamic parameters in feed. Was guided by hospital treatment for 16 days. According to the diaries, the condition is satisfactory. Discharged to work. The clinical diagnosis is concussion. During the forensic medical examination, the diagnosis of a concussion of the brain was removed as unfounded, and the bruises and abrasions that were present were assessed as bodily injuries that did not entail any harm to health. If the diagnosis - a concussion of the brain was justified, then the damage would qualify as a slight harm to health. By the way, it should be noted that the description of the injuries boiled down to one phrase "there are multiple abrasions and bruises on the body in various areas." There is no localization, no quantity, no color indicating how long ago the damage was caused. As a result, the important day of the investigation, questions about localization, the duration of the formation of injuries, the number of blows inflicted remained unanswered.

It is necessary to dwell on the importance of records in the medical history of alcohol intoxication of the victims admitted to the hospital.

Many victims are admitted, and medical institutions are in a state of alcoholic intoxication. Some of them immediately from the scene "where the injury was received.

When such persons are admitted to a hospital to provide medical care, it is often the case that the victim was drunk at the time of the injury is made only on the basis of records in the medical history. mouth or preliminary alcohol tests using Mohoya-Shchinkarenko tubes. Smell is a purely subjective perception. And the Rappoport test, based on the study of exhaled air through the Mokhov tubes, is not specific and gives a positive result in cases where the air contains oxidizing substances.

The conclusion about the presence and degree of alcoholic intoxication should be based on objective, recorded studies. This decision was approved back on December 22, 1954 by order of the USSR Ministry of Health No. 523. This provision is still valid today. Patients admitted to the emergency room undergo a blood alcohol test, which is currently performed using gas-liquid chromatographs. These devices determine the quantitative content of alcohol in blood and urine, on the basis of which it is possible to draw a reasonable conclusion about alcohol intoxication, its degree and stage / absorption or elimination /, and therefore, if necessary, it is possible to calculate the time when alcohol was taken and check the indications the victim in relation to the amount of alcohol consumed in terms of pure ethanol. For this, a number of formulas proposed by Widmark are used. If it is necessary to carry out such calculations, you can use the manual "Forensic examination of poisonings" edited by R.V. Berezhny. with coauthors. M- Medicine. 1990. pp. 210-255.

An important component and very responsible part of the medical history is the clinical epicrisis, i.e. a doctor's conclusion on the nature and clinical course of the disease / injury /, on the condition of the patient or victim at the time of discharge from the hospital, on the treatment carried out, on the prognosis, recommendations, on rehabilitation and further regimen.

The case history and records in it acquire particular importance when investigating cases of professional offenses of medical workers, when considering complaints of patients and relatives in various instances about untimely or inadequate treatment, when there are reasons to think about wrong actions, as well as doctor's negligence. This is usually observed with a sharp deterioration in the patient's state of health "or at his death.

Analysis of materials at clinical and anatomical conferences, departmental checks during the investigation show that in most such cases the accusations of doctors turn out to be unfounded, tk. the disorder in the health of patients or their death is due to the severity of the disease or injury. But sometimes it turns out that accusing doctors of an unfavorable outcome of treatment is more or less fair.

In any case, the medical history, along with the conclusion of the forensic medical examination, is of decisive importance for clarifying the legality of the actions of medical workers. According to the records in it, they judge the correctness of diagnosis and treatment, the need, timing and technique of surgical intervention and other medical actions.

The entire history of the disease is thoroughly analyzed, and especially those parts of it that reflect the initial state of the patient, the rationale for the diagnosis and the chosen method of treatment, data on surgical and other manipulations.

Careless filling out of case histories, standard general phrases in the diary, for which it is difficult to draw specific conclusions about the course of the disease or injury, erasures and corrections, the lack of records on the patient's consent to a particular intervention / operation /, about the examination results by invited consultants and already by themselves can create an idea of ​​the doctor's dishonest attitude to his duties, of insufficient responsibility in the performance of official duties. In such cases, references to official employment sound extremely unconvincing, in connection with which there is little time left to work with the medical history, references to illegible handwriting, etc., which one hears from the doctor interrogated by the investigator.

So, in one observation of a water worker, the question of the cause of a fatal post-transfusion complication that developed in a patient. It was assumed that blood group incompatible was transfused. According to the medical history, it was impossible to establish who made the determination of the blood group, there was no information about the conduct and results of a compatibility test, about the amount of blood transfused. Labels from used blood vials turned out to be lost.

In another case, it was required to establish the correctness of the actions of the dentist who removed the 7th right tooth in the upper jaw from a 35-year-old man. After extraction of the tooth, purulent periostitis developed, and then submandibular phlegmon, purulent mediastinitis, bilateral pleurisy and pericarditis, which ultimately led to death. In the process of forensic medical examination, carried out in connection with the complaint of a relative of the deceased about improper treatment, it was necessary to determine the source of infection of the organism. It was assumed "that the tooth was not completely removed, the root part remained" and, being infected, caused further complications. This circumstance necessitated the exhumation of the corpse, but the relatives did not give such consent and the exhumation was not carried out. The question remained unresolved,

It should be emphasized that carrying out an exhumation does not always resolve all issues. Often, its implementation is complicated by purely technical reasons / winter /, often this procedure is morally difficult for the relatives of the deceased. But it is not uncommon for it to be ineffective in itself. This happens when the corpse has undergone decomposition. However, in case of injuries associated with damage to the bones of the skeleton, exhumation, regardless of the age of limitation, is always useful to one degree or another to resolve investigative issues.

The medical history is an important source of evidence in the investigation of criminal cases of simulation, aggravation, self-mutilation with the aim of evading the duties provided for by the law ”, first of all, from military service.

Suspects of self-harm or simulation are admitted to medical institutions, and a medical history is drawn up on them, in which objective data relating to the injury or illness are recorded. In these cases, the forensic medical examination will be completely based on the data of medical documents, therefore, its results will completely depend on the correctness and quality of the medical history.

We must not forget also about the importance of describing the removed organs and tissues in the history of the disease.

Medical history data, like other medical records, can go a long way in identifying an individual.

So, an example comes to mind when the corpse of an unknown man was examined. The examination revealed cavernous pulmonary tuberculosis. An X-ray of the lungs was taken. The cavernous cavity looked like a figure eight. The X-ray data in the morgue were handed over to operational workers. They checked the X-ray archives of hospitals and tuberculosis dispensaries. Several images were selected with a similar shape of the caverns. By comparing posthumous and lifetime photographs, a specific citizen was identified. This result was confirmed by portrait blending.

All of the above is quite clear, in our opinion, it shows a really large scientific and practical, therapeutic, diagnostic and legal role of medical documentation.

In conclusion, I would like to add that today, in connection with the working conditions in the systems of compulsory and voluntary health insurance, the medical history has another function - control of the quality and completeness of examination, treatment, and rehabilitation. It is studied and evaluated not only by the medical control commission of the hospital, but also by independent medical experts from insurance companies. If the medical records are poorly filled out, then even with sufficient treatment, insurance companies will be able to make claims to the medical institution regarding the volume and quality of medical services, and therefore not pay extra money, which ultimately will affect your personal monetary remuneration.

CONTROL QUESTIONS TO DETERMINE END LEVEL OF KNOWLEDGE:

1. What documents are called "medical records"?

2. What is the concept of the state standard of medical documentation?

3. The purpose of medical records, the role of the State Statistical Reporting?

4. When was its author included in the list of medical records "Case history"?

5. What sections / by state. standard / includes medical history?

6. What are the requirements for making a medical history?

7. Therapeutic and diagnostic purpose of the medical history?

8. Scientific and practical value of the medical history?

9. The legal significance of the medical history?

10. Conducting forensic medical examinations on medical documents / reasons, requirements for honey. documentation /?

11. Expertise in "Medical Cases"?

12. The role of forensic medical examination in resolving issues related to professional offenses of medical workers?

13. Give the definition of "Crime". Potential Criminal Occupational Crimes for Healthcare Professionals?

14. The ratio of legal and moral and ethical standards in medicine?

LITERATURE

1. The text of the law,

2. Malenina M.N. Man and medicine in modern law. M., 1995.

3. Lecture material.

CRIMINAL CODE OF THE RUSSIAN FEDERATION

/ excerpts /

CHAPTER II

DIAGNOSTIC THINKING:

ABOUT PSYCHOLOGICAL REASONS FOR MEDICAL ERRORS

2.1. The concept of medical errors, their classification.

Objective and subjective reasons for medical errors.

Above, the psychological foundations of communication between a doctor and a patient were considered, on which the success of the entire diagnostic work of a doctor largely depends.

As in any other complex mental activity, incorrect hypotheses are possible in the diagnostic process (and the formulation of a diagnosis is the advancement of hypotheses, which are either confirmed or rejected in the future), diagnostic errors are possible.

In this chapter, the definition and essence of the very concept of "medical errors" will be analyzed, their classification is given, the reasons for the occurrence of medical errors, in particular diagnostic errors, are considered, and their significance in the course and outcome of diseases is shown.

Unfavorable outcomes of diseases and injuries (deterioration of health, disability, even death) are caused by various reasons.

The first place should be given to the severity of the disease itself (malignant neoplasms, myocardial infarction, other forms of acute and exacerbation of chronic ischemic heart disease, and many others) or trauma (incompatible with life or life-threatening damage, accompanied by severe shock, bleeding and other complications , burns III– IV degrees of significant body surfaces, etc.), poisoning with various substances, including medicinal, andalso various extreme conditions (mechanical asphyxia, extreme temperatures, electricity, high or low atmospheric pressure), etc.

Late seeking medical help, self-medication and treatment by healers, criminal abortions also often lead to serious consequences for the health and lives of people.

A certain place among the unfavorable outcomes of diseases and injuries is occupied by the consequences of medical interventions, late or erroneous diagnosis of a disease or injury. This could result from:

1. Illegal (criminally punishable) deliberate actions of medical workers: illegal abortion, failure to provide medical care to a patient, violation of rules specially issued to combat epidemics, illegal distribution or sale of potent or narcotic substances, and some others.

2. Illegal (criminally punishable) careless actions of medical workers that have caused significant harm to the life or health of the patient (negligence in the form of non-fulfillment or dishonest performance of their official duties; grave consequences as a result of gross violations of diagnostic or therapeutic measures, non-observance of instructions or instructions, for example, transfusion of non-group blood due to violations of the instructions for determining the group belonging of blood), when the doctor or paramedical worker had the necessary opportunities for the correct actions to prevent the development of complications and related consequences.

Criminal liability in these cases occurs if a direct causal link is established between the action (inaction) of a medical worker and the serious consequences that have occurred.

3. Medical errors.

4. Accidents in medical practice. Not a single person, even with the most conscientious performance of his duties, in any profession and specialty, is free from erroneous actions and judgments.

This was recognized by V.I.Lenin, who wrote:

“He is not smart who does not make mistakes. There are no such people and cannot be. He is smart who makes mistakes that are not very significant and who knows how to easily and quickly correct them. ”(V. I. Lenin - Childhood disease of "leftism" in communism. Collected essays, ed. 4, t. 31, L., Politizdat, 1952, p. nineteen.)

But the mistakes of a doctor in his diagnostic and therapeutic work (and preventive, if it concerns a sanitary doctor) differ significantly from the mistakes of a representative of any other specialty. Suppose an architect or builder makes a mistake when designing or building a house. Their mistake, although serious, can be calculated in rubles, and, ultimately, the loss can be covered in one way or another. Another thing– doctor's mistake. The famous Hungarian obstetrician-gynecologist Ignaz emmelweis (1818– 1865) wrote that with a bad lawyer, the client risks losing money or freedom, and with a bad doctor, the patient risks losing his life.

Naturally, the issue of medical errors worries not only the doctors themselves, but also all people, our entire community.

Analyzing medical errors, it is necessary to define them. It should be noted right away that lawyers have no concept of “medical error” at all, because a mistake is not a legal category at all, since it does not contain signs of a crime or misconduct, that is, socially dangerous acts in the form of an action or inaction that have caused a significant (crime) or insignificant (misconduct) harm to the rights and interests of the person protected by law, in particular health or life. This concept was developed by physicians, and it should be noted that at different times and by different researchers different content was put into this concept.

Currently, the generally accepted definition is: medical error– it is the doctor's conscientious delusion in his judgments and actions, unless elements of negligence or medical ignorance are allowed.

I.V.Davydovsky with coauthors (Davydovsky I.V. et al.Medical errors. Great medical encyclopedia. M., Sov. encyclopedia, 1976, vol. 4, p. 442– 444.) give the same definition in essence, but in slightly different words: "... a doctor's mistake in the performance of his professional duties, which are the result of a conscientious delusion and do not contain corpus delicti or signs of misconduct."

Consequently, the main content of this concept is an error (incorrectness in actions or judgments), as a result of a conscientious delusion. If we talk, for example, about diagnostic errors, then this means that the doctor, having questioned and examined the patient in detail using the methods available under certain conditions, nevertheless made a mistake in the diagnosis, mistaking one disease for another: in the presence of symptoms of an "acute abdomen", he considered that they indicate appendicitis, but in fact the patient developed renal colic.

Questions to consider: Are medical errors inevitable? What medical errors are encountered in medical practice? What are their reasons? What is the difference between medical errors and unlawful actions of a doctor (crimes and misconduct)? What is the responsibility for medical errors?

Are medical errors inevitable? Practice shows that medical errors have always occurred, since ancient times, and they can hardly be avoided in the foreseeable future.

The reason for this is that the doctor deals with the most complex and perfect creation of nature.– with a person. The physiological processes occurring in the human body, and even more so, the pathological processes have not yet been fully studied. The nature of even pathological processes of the same type in terms of clinical manifestations (for example, pneumonia) is far from unambiguous; the course of these changes depends on many factors, both in the body itself and outside it.

The diagnostic process can be compared to the solution of a multivariate mathematical problem, an equation with many unknowns, and there is no single algorithm for solving such a problem. The formation and substantiation of a clinical diagnosis is based on the doctor's knowledge of the etiology, pathogenesis, clinical and pathomorphological manifestations of diseases and pathological processes, the ability to correctly interpret the results of laboratory and other studies, the ability to fully collect an anamnesis of the disease, as well as taking into account the individual characteristics of the patient's body and related features the course of the disease in him. To this we can add that in some cases the doctor has little time (and sometimes lacks the opportunity) to study the patient and analyze the data obtained, and the decision must be made immediately. The doctor will have to decide for himself whether the diagnostic process is over or should continue. But in fact, this process continues throughout the observation of the patient: the doctor is constantly looking for either confirmation of his hypothesis of the diagnosis, or rejects it and puts forward a new one.

Even Hippocrates wrote: “Life is short, the path of art is long, the opportunity is fleeting, judgment is difficult. Human needs make us decide and act. "

With the development of medical science, the improvement of existing and the manifestation of new objective methods of establishing and registering the processes occurring in the human body, both in norm and in pathology, the number of errors, in particular diagnostic ones, decreases and will decrease. At the same time, the number of errors (and their quality), caused by insufficient qualifications of a doctor, can be reduced only with a significant increase in the quality of training of doctors in medical universities, an improvement in the formulation of postgraduate training of a doctor and, especially, with the purposeful independent work of each doctor to improve his professional theoretical knowledge and practical skills. Naturally, the latter will largely depend on the personal and moral and ethical qualities of the doctor, his sense of responsibility for the task entrusted to him.

What are the causes of medical errors?

These reasons can be divided into two groups:

1. Objective, that is, independent of the doctor himself and the degree of his professional training.

2. Subjective, directly dependent on the knowledge and skills of the doctor, his experience.

For objective reasons, it should be pointed out that the etiology and clinic of a number of diseases, in particular, rare ones, are insufficiently studied. But the main objective reasons for medical errors are the lack of time to examine the patient or victim of trauma (in urgent cases requiring immediate solutions and medical intervention), the lack of the necessary diagnostic equipment and apparatus, as well as the atypical course of the disease, the patient has two or even more diseases. IV Davydovsky said well about this: “... medicine is not a technique, where exact sciences dominate– physics, mathematics, cybernetics, which are not the basis of the logical operations of a doctor. These operations, like the research itself, are especially difficult because not an abstract disease lies on a hospital bed, but a specific patient, that is, there is always some kind of individual refraction of the disease ... the main, most objective cause of medical errors is rooted in the individual factor and no guidance, no experience can guarantee the absolute faultlessness of the doctor's thoughts and actions, although, as an ideal, this remains our motto. "

It would be wrong to see in this statement of the famous scientist, who has devoted more than half a century to the study of mistakes in the professional activities of doctors, some kind of justification for mistakes and omissions made by doctors, an attempt to justify them with objective reasons. In his other works, I.V. Davydovsky analyzes and summarizes the causes of errors, which are the most frequent,- subjective.

The most common are errors in the diagnosis of diseases. S. S. Weill (Errors in clinical diagnosis. Ed. S. S. Weil. L., 1969, p. 6.) analyzes in detail their reasons, both subjective and objective. He points to the following subjective reasons:

1. Poor collection of anamnesis and not quite thoughtful use of it.

2. Lack of laboratory and X-ray studies, incorrect conclusions of radiologists and insufficient critical attitude of clinicians to these conclusions.

Speaking about this, by the way, not uncommon, reason, it should be noted that by themselves both radiographs and laboratory preparations, such as blood smears, histological preparations, very objectively reflect this or that phenomenon: they fix a fracture, ulcer, tumor or other pathological phenomena, deviations in the composition of blood cells, etc. But the assessment of these changes is subjective, depends on the knowledge of the doctor, his experience. And, if this knowledge is not enough, then errors in the assessment of the detected changes may occur, which can lead to an incorrect diagnosis.

3. Improper organization of consultations, in particular, correspondence consultations, without the participation of the attending physician of consultations, underestimation or overestimation of the opinion of consultants.

4. Inadequate generalization and synthesis of anamnesis data, symptoms of the disease and the results of examination of the patient, inability to use all these data in relation to the peculiarities of the course of the disease in a particular patient, especially in its atypical course. To the subjective reasons for erroneous diagnostics, which S.S. Weil lists, one more should be added: failure to comply with the minimum of mandatory studies, as well as other studies that could be performed.

We have given only subjective reasons. Analyzing them, it is easy to notice that in most of them we are talking not only about the wrong actions of the doctor, as a result of his insufficient qualifications, but also about the failure to comply with the actions obligatory for the doctor. So, it is impossible to justify the lack of qualifications and little experience neglect of anamnesis, disuse opportunities to consult with experienced doctors, failure to carry out those laboratory or functional studies that could be done. In such cases, we can talk about the presence of elements of negligence in the actions of the doctor, and there will be no reason to assess the consequences of these actions as a medical error. What will be said in chapter II of this manual about the influence of the individual psychological characteristics of a doctor on the diagnostic process is directly related to the occurrence of diagnostic errors for subjective reasons. In particular, this refers to such qualities as the methods of obtaining, storing and processing information received by the doctor in the process of diagnosis, the degree of sensitivity of the doctor's analyzer systems, the peculiarities of the doctor's memory, the properties of his attention, switching, attention stability, etc.

From what has been said, it logically follows that the measure of preventing diagnostic errors should be constant professional improvement of the doctor (first of all, in the form of self-improvement), in increasing his knowledge and practical skills. Along with this, the doctor must be able to admit his mistakes, analyze them in order to avoid similar ones in his future work. An example in this respect was set by the great Russian surgeon II. I. Pirogov, who made his mistakes public, rightly believing that it is possible "... by a truthful open confession of their mistakes and by disclosing an intricate mechanism to save their students and novice doctors from repeating them."

In the occurrence of diagnostic errors, and deontological qualities of a doctor: his attentiveness and conscientiousness, willingness to consult a more experienced doctor, a sense of responsibility.

Practice shows that diagnostic errors are made not only by young, but also by experienced doctors with high professional training and long work experience. But they are wrong in different ways. Young doctors make mistakes more often and in rather simple, from the point of view of diagnostics, cases, while experienced doctors make mistakes in complex and confusing cases. IV Davydovsky wrote: “The fact is that these (experienced) doctors are full of creative daring and risk. They do not run away from difficulties, that is, cases that are difficult to diagnose, but boldly go to meet them. For them, high-ranking representatives of medicine, the goal is– save the sick– justifies the means. "

What medical errors are encountered in practice? Currently, most researchers distinguish between the following main types of medical errors:

1. Diagnostic.

2. Errors in choosing a method and conducting treatment (they are usually subdivided into therapeutic and technical and therapeutic and tactical).

3. Errors in the organization of medical care. In addition to those listed, some authors also distinguish between errors in the maintenance of medical records. If we talk about these errors, then in their occurrence, as well as in the occurrence of medical and technical errors, objective reasons should be completely excluded. Here we can only talk about the shortcomings of the training of a doctor, that is, the subjective reason for the occurrence of these errors.

Our task was to analyze diagnostic errors and their causes, since they are more common and, in most cases, determine errors of a therapeutic nature, although in some cases errors in treatment are also encountered with a correct diagnosis.

A large literature is devoted to a detailed analysis of all types of medical errors.

(Errors of clinical diagnosis, under the editorship of S. S. Vail, L., 1969, p. 292;

N.I. Krakovsky. Yu.Ya. Gritsmag– Surgical errors. M., 1967, p. 192;

S. L. Libov - Errors and complications in heart and lung surgery, Minsk 1963, p. 212;

V. V. Kupriyanov, N. V. Voskresensky– Anatomical options and errors in the practice of the doctor, M., 1970, p. 184;

A. G. Karavanov, I. V. Danilov– Errors in the diagnosis and treatment of acute diseases and injuries of the abdomen, Kiev, 1970, p. 360;

M.R.Rokitsky - Errors and dangers in surgery of children, M., 1979, p. 183; Diagnostic and treatment errors of the doctor. Sat. scientific works, Gorky, 1985, p. 140.)

What is the responsibility for medical errors?

It was already noted above that in cases of medical errors, in which there are no elements of negligence or medical ignorance, the question of the doctor's legal (administrative or criminal) liability is not raised. However, in all cases moral responsibility remains. A real humanist doctor with a heightened sense of duty cannot help but think about the mistake he has made and its consequences, cannot help but worry, and for every mistake his conscience passes a sentence on him, and this sentence of conscience can be heavier than a human sentence.

Each error must be analyzed by the medical team. It is necessary to establish the causes and conditions of the error in each specific case. When analyzing and analyzing the causes of errors, it is necessary to resolve the question: could a doctor, in objectively prevailing conditions, with his qualifications and a conscientious attitude to the matter, avoid mistakes? In hospitals, this is done at meetings of treatment and control commissions and clinical and anatomical conferences with the participation of pathologists or forensic experts. Such conferences are a good school not only for training, but also for the education of doctors and other medical workers.

The outstanding Soviet clinician and scientist I. A. Kassirsky wrote in the monograph "On Healing", which must be carefully studied by every doctor: "Errors - the inevitable and sad costs of medical activity, mistakes are always bad, and the only optimal thing that follows from the tragedy of medical errors is that they teach in the dialectic of things and help to ensure that they do not exist ... they carry in their essence the science of not being wrong, and it is not the doctor who makes the mistake that is guilty, but the one who is not free from cowardice to defend it. " (I.A.Kassirsky- "About healing" - M., Medicine, 1970, p. 27.)

Accidents in medical practice.

Only a person guilty of committing a crime, that is, deliberately or recklessly committed a socially dangerous act provided for by law, is subject to criminal liability and punishment.

According to Soviet laws, socially dangerous consequences of a person's actions (or inaction) cannot be imputed if he did not foresee and could not foresee these socially dangerous consequences.

Here we can talk about a case, that is, about an event that is not caused by someone's intent or negligence, and therefore there is no deliberate or careless fault in the actions (inaction) of this or that person. In medicine, it is customary to talk about accidents in medical practice, which are understood as such unfavorable outcomes of medical intervention (in diagnosis or treatment), which, according to the data of modern medical science, could not be objectively foreseen and, therefore, could not be prevented.

Accidents in medical practice occur as a result of unfavorable circumstances, and sometimes on the individual characteristics of the patient's body, which do not depend on the will or actions of medical workers.

The circumstances under which accidents occur and the reasons that cause them are rare. So, accidents include severe allergies, up to the death of the patient, due to intolerance to the drug (often antibiotics) at the first contact of the patient with it; the so-called "anesthetic death" with shown and impeccably performed anesthesia. The causes of "anesthetic death" are not always established, even with pathological examination of the corpse. In such cases, the reasons for unfavorable outcomes lie in the peculiarities of the patient's functional state, which could not be taken into account even with the most conscientious actions of the doctor.

If the unfavorable outcome of the diagnostic or therapeutic intervention was caused by insufficient, negligent or incorrect actions of the doctor from the point of view of medical science, then there are no grounds for recognizing the results of these actions as an accident.

// L.M. Bedrin, L.P. Urvantsev Psychology and deontology in the work of a doctor. - Yaroslavl, 1988, pp. 28-36

see also:

In medical practice, there are often situations when, due to the mistakes of medical workers, patients are seriously injured or even die. Most often, doctors describe these situations as an unintentional act. However, if it is established that the cause of the tragedy was the medical negligence or carelessness of the physician, the error quickly turns into a criminal offense, for which the doctor will be punished.

The legislator has not yet given a clear definition of the concept of medical error. You can catch a glimpse of it in the "Fundamentals of the legislation of the Russian Federation on health protection" and the Federal Law "On compulsory insurance of patients in the provision of medical care." At the same time, the criminal legislation does not contain any rules on this concept at all.

Therefore, the wording of the definition can be very diverse. Most often, there are such interpretations of the concept of medical error by classification:

• the inability of the health worker to use in practice theoretical knowledge in the field of medicine and the abandonment of the patient without qualified assistance as a result of the inaction of the attending physician;
• incorrect diagnosis of the patient and incorrectly prescribed medical procedures due to the delusion of the doctor;
• medical error in the performance of their professional duties as a result of delusion, which does not have any corpus delicti;
• the result of the professional activity of a doctor who, due to some neglect, made a mistake in his professional field, but it is in no way associated with inactivity or negligence.

Whatever interpretation the user chooses, the result will still be the same. Depending on the damage received, the patient can either go to court.

Due to a mistake, the patient's health is exposed to unprecedented danger, and can lead to death.

Medical error, in fact, refers to generic concepts, and therefore it is classified according to the following crimes:

• Article 109 of the Criminal Code of the Russian Federation - causing death by negligence;
• Article 118 of the Criminal Code of the Russian Federation - injury to health of increased severity through negligence;
• Article 124 of the Criminal Code of the Russian Federation - inaction of the medical staff and failure to provide timely assistance.

In Western Europe and the United States, there are regulations in the medical industry, and any mistake will violate the approved rules. Consequently, the offender will be held liable for his or her misconduct. In Russia, such a court practice is not used, and therefore it can be incredibly difficult to prove that a doctor made a mistake due to negligence or for other reasons. However, if it is established that the doctor had all the necessary knowledge and resources to provide timely assistance, but did not do this due to certain circumstances, then the negligence of the doctors will be recognized, for which he will be held liable.

In any situation, the law will first of all take the side of the victim, since a medical error is considered a criminal offense. However, it has a very large number of features, including:

1. Most often, the error occurs due to coincidence and does not imply any bad intentions on the part of the medical staff. This already makes it possible to mitigate the sentence to the attending physician, if it is not communicated that his actions (inaction) are malicious in nature.
2. The objective basis for the occurrence of an error may consist of a number of factors, including inattention, lack of experience and qualifications, negligence. All of them can serve as a reason for commutation of punishment.
3. The subjective reasons for doctors' mistakes are ignoring the approved rules, neglecting medications and negligence in carrying out any examinations. Such reasons in legal proceedings may lead to increased liability.

In order to determine at what stage of work with the patient mistakes were made, it is customary to classify them according to the following types:

• diagnostic, which are most common, at the stage of examining a patient, the doctor does not take into account the specifics of the human body and makes an incorrect diagnosis;
• organizational, associated with a lack of material support for a medical institution, as well as an insufficient level of medical care;
• treatment and tactical errors, this type arises on the basis of an erroneous diagnosis, and the medical measures taken can lead to a deterioration in the state of human health;
• deontological, associated with the unsatisfactory psychophysical state of the doctor, and his wrong line of behavior with patients, their relatives and other medical staff;
• technical, they are associated with improper execution of a medical record or a patient's discharge;
• pharmaceutical, which appear due to the fact that the specialist incorrectly determines the indications and contraindications, and also does not pay attention to the compatibility of various groups of medications.

If you want to delve deeper into this topic and learn about what medical secrecy is, then read about it.

Causes of medical errors

Medical error occurs in situations where a certain action or inaction of a health worker caused a deterioration in the patient's condition or death. If it is determined that the error is directly related to negligence in job descriptions or negligence, the doctor will be punished.

The reasons that led to the appearance of medical errors are subjective and objective. The most striking example of an objective cause is the atypical behavior of the disease and its impact on human health. So, if a new stamp of the virus has appeared, which has not yet been sufficiently studied, and as a result of treatment, damage has been caused, the doctor will not be held liable, since here the error will be associated with a lack of intent.

As for the subjective reason, the situation here will be somewhat different. So, a mistake can occur due to a lack of experience with a doctor, incorrect filling of medical records or inappropriate behavior.

Criminal liability will be established in accordance with the current legal framework.

Characteristics of the crime

Since there is, in principle, no separate standard for doctors who have made a mistake in the professional sphere, a priori negligent actions of medical personnel are considered as neglect of official duties, which are designed to regulate professional activities.

Acting as an official, a doctor can commit a crime in situations where the patient has died or his health condition has deteriorated sharply. In view of this, the corpus delicti will consist of various factors:

1. Objectivity. It is expressed in the presence of certain duties and instructions, which the doctor has neglected due to negligence, inattention to detail, or underestimation of the severity of the disease. However, if the disease exhibits atypical characteristics, then the causal relationship will be uncertain, and the medical staff will be released from punishment.
2. Subjectivity, expressed by the presence of a medical professional whose actions led to the appearance of negative consequences for the patient's health, or death.
3. The flaw in fixing an event (deterioration in health or death), which is directly dependent on the prescribed treatment procedures and the chosen treatment method.

If all three factors take place, then the doctor's crime will be classified according to Article 293 of the Criminal Code of the Russian Federation, and a certain type of punishment will be established for the negligence of doctors. Qualified medical error lawyers will help you achieve justice.

Responsibility for medical error

There are three types of liability for medical error:

1. Disciplinary. In this situation, the error was revealed by an internal investigation and a thorough analysis of the doctor's actions. If the harm caused is minor, the offender will be fined, sent for retraining, deprived of positions or transferred to another place of work. Also, a reprimand will appear in the doctor's work book.
2. Civil law. If, as a result of the doctor's actions, the patient is harmed, he can demand monetary compensation, including compensation for damage, the cost of all additional medicines and care, moral compensation.
3. Criminal proceedings imposed in situations where the user has received substandard medical services resulting in serious harm to health or death. In situations where the damage is minor, it will be impossible to initiate criminal prosecution of the doctor. In addition, there will be a deprivation of the right to practice medicine in the foreseeable future for a certain period.

As an example of criminal proceedings on this topic, one can name the following situations:

• an illegal abortion was carried out, due to which the woman was seriously injured or died, the offender will be punished under Part 3 of Article 123 of the Criminal Code of the Russian Federation;
• due to the doctor's neglect, the patient was infected with HIV, in this situation the doctor will serve his sentence in prison for 5 years in accordance with the provisions of part 4 of article 122 of the Criminal Code of the Russian Federation;
• illegal medical and pharmaceutical assistance will be punished under Part 1 of Art. 235 of the Criminal Code of the Russian Federation, if it is a lethal outcome, the case will be classified under Part 2 of Art. 235 of the Criminal Code of the Russian Federation, but it will be difficult, and a good lawyer will be required;
• failure to provide assistance, entailing harm of moderate or mild degree will be considered under Art. 124 of the Criminal Code of the Russian Federation, if the injuries are more serious, the medical worker will go under Part 2 of Article 124 of the Criminal Code of the Russian Federation;
• in the case of an established case of medical negligence and disregard of current standards, the person responsible will be convicted in accordance with part 2 of article 293 of the Criminal Code of the Russian Federation.

Note that the injured party is entitled to full compensation.

In the event of initiation of criminal proceedings, the victim also has the right to sue for compensation for the damage caused. This is indicated in Art. 44 of the Code of Criminal Procedure of the Russian Federation, the legislator does not establish clear amounts of monetary compensation, therefore the level of damage in monetary terms is to be assessed by the user independently.

It is worth saying that the amount of compensation will consist of material and moral damage. In the first case, this will include all costs of expensive treatment and purchase of drugs, as well as payment for additional care services. If the user is disabled, this will also be taken into account. With regard to non-pecuniary damage, the victim can request any amount, provided that its amount is not greatly exaggerated.

Where to go and how to prove a medical error

The law always guards the interests of the patient, so you should not be afraid to defend your point of view. In cases where there is a medical error that cost the victim health or life, users will have to contact the following officials and authorities:

1. Administration of a medical institution. The clinic's management will need to clarify the problem in detail and provide evidence. After the official proceedings, in case of proof of guilt, the health worker will be brought to disciplinary responsibility.
2. Insurance Company. If there is insurance, the victim or his representative will have to visit the insurers and explain the situation to them, which will show whether the medical staff is really guilty of the situation. If the applicant's version is confirmed, penalties will be imposed on the doctor and clinic.
3. Courts. A claim must be sent here, in which the situation and the applicant's requirements will be carefully spelled out. In addition, the user will have to take care of collecting the evidence base. Based on the claim, legal proceedings will be opened, and if everything is confirmed, the plaintiff will receive compensation.
4. Prosecutor's Office. You have to contact here if the user intends to initiate a criminal case. Note that the proceedings will be long, and will be followed by serious consequences for the offender.