告知醫療錯誤

1. 告知醫療錯誤 楊秀儀 2005/11/21

2. To all healthcare professionals who did the right thing, when doing the right thing was very very difficult. John Banja Medical Errors and Medical Narcissism

3. What is right in medical malpractice cases? • 台灣醫療糾紛爭訟中，病人敗訴率高 • 醫界常見的說法：若該件事件，醫師有過失，早就理賠了；故上法院的案件中，本就是醫師沒有過失的情形居多 • 質疑：除非明顯過失，否則因為醫療的高度專業性，一般人根本無從去爭執醫師的過失。掩飾過失比承認過失容易 • 舉例：一婦產科醫師於接生後天忘記將置放於產婦陰道中的紗布取走，間隔達42天之久，但醫師仍振振有詞的主張，其有醫療之必要性。

4. 想想這些案例： • 小明放學後在家的附近和弟弟打棒球，弟弟投出一個又直又軟的慢速球，小明奮力一揮，「砰」，竟將鄰居陳太太家的玻璃打破了。但此時陳太太正好全家都不在家。 • 你是小明的爸爸，小明告知你此事，你會教他怎麼作？

5. 案例二： 李先生在經過多年的辛勤工作後，存了一筆錢。他的願望就是將家中又窄又暗的小浴室改裝成五星級飯店般乾濕分離的豪華空間。經過3星期的施工，一家人都很滿意最後的成果。洗澡也成了李家一件愉悅的事。但8月的一場颱風過後，新浴室的馬桶卻不時的阻塞。找人檢修的結果是：當初包商將用剩的水泥就直接倒入馬桶中，以致於造成水管狹窄，遇有大雨便會阻塞。李先生此時豁然瞭解原來住在樓下的王小姐其天花板漏水的原因。但王小姐只是房客，房東林先生則長期定居國外。

6. 案例三 甲為某大學的研究生，為賺取學費下課後至麥當勞打工，10點打烊後再回研究室作實驗。某日半夜騎車返家的途中，因為太過疲倦，一個閃神，輪胎似乎撞倒東西。下車一看，竟然有一個人倒臥血泊之中，其渾身酒氣沖天，但不幸已經死亡。甲萬分驚恐，但並不明白究竟此一事件的原因為何？是甲將其撞死的嗎？還是該人原本就受傷躺在路上？還是甲只不過撞上了一個屍體？ 此時夜深人靜，四下無人。甲相當確定事發當時沒有任何目擊證人。 甲該怎麼作？

7. 案例四 • 年輕的B小姐患有輕度精神分裂症，並有自殺傾向。曾多次自殺，但都送醫急救後存活。一日深夜12點左右，B小姐打電話給家人，告知其在鄰近的公園，已經吞食了200顆的安眠藥。家人聞訊急忙將B小姐送往附近的H大醫院急診室。急診醫師趕忙替B小姐催吐，洗胃；過程中，因為B小姐情緒激動，所以用束縛帶將其固定在病床上，未料護士不注意，液體流入B小姐的氣管中，導致B小姐呼吸困難，進而休克。雖急救後恢復生命跡象，5天後，B小姐死於吸入性肺炎。

8. 誠實最上策？ • 前述四個例子，你的答案是什麼？ • 想想你是受害人的話，你希望答案是什麼？ • 若你是法官，你認為係爭當事人之間正當的舉動是什麼？ • 在一個公義的社會中，前4個案子應該如何解決？

9. 為什麼認錯這麼難？ • 歸咎文化使得認錯比文過飾非更困難 • The old paradigm of blaming and punishing individuals led to overreliance on flawless personal performance and to the hiding of mistakes out of shame and fear if they occurred. • Albert Wu conducted an anonymous study of 114 house officers regarding their most significant mistakes. Only 54% had discussed their mistake with their attending physician, and only 24% told the patients and families. • Wu AW. Do house officers learn from their mistakes? JAMA. 1991, 265: 2089-2094

10. Patients' and Physicians' Attitudes Regarding the Disclosure of Medical Errors Thomas H. Gallagher, MD; Amy D. Waterman, PhD; Alison G. Ebers; Victoria J. Fraser, MD; Wendy Levinson, MD JAMA. 2003;289:1001-1007. • Context  … little is known about how patients and physicians think medical errors should be discussed. • Objective To determine patients' and physicians' attitudes about error disclosure. • Design, Setting, and Participants Thirteen focus groups were organized, including 6 groups of adult patients, 4 groups of academic and community physicians, and 3 groups of both physicians and patients. A total of 52 patients and 46 physicians participated.

11. . • Results  • Patients wanted disclosure of all harmful errors and sought information about • what happened, • why the error happened, (x) • how the error's consequences will be mitigated, • and how recurrences will be prevented. (x) • Physicians agreed that harmful errors should be disclosed but "choose their words carefully" when telling patients about errors. Although physicians disclosed the adverse event, they often avoided stating that an error occurred, why the error happened, or how recurrences would be prevented.

12. 錯誤告知對醫病雙方的心理意義 • 醫師的認錯與道歉對受到醫療傷害的病人而言，有治療上的意義，但是醫師們對未來醫療糾紛的恐懼使得他們傾向文過飾非。 • 一個有害的錯誤發生了，犯錯的人自己也有心理上的創傷需要情緒支持，認錯，道歉，並得到病人的原諒對當事醫師而言，也有治療的意義。 • 病人原諒醫師對病人本身也有治療意義

13. 現狀的問題 • 醫療機構有提供專業服務與情緒支持，協助發生醫療錯誤的醫師如何與病人溝通，討論錯誤嗎？ • 醫學教育有訓練醫師，如何與病人溝通，討論錯誤嗎？

14. Subtracting insult from injury: addressing cultural expectations in the disclosure of medical error N Berlinger and A W Wu • … while physicians may express a need for self-forgiveness after making errors and should be aware that patients may also rely upon forgiveness as a means of dealing with harm. • … learning how to disclose errors, apologise to injured patients, ensure that these patients’ needs are met, and confront the emotional dimensions of one’s own mistakes should be part of medical education and reinforced by the conduct of senior physicians.

15. Communicating With Patients About Medical Errors A Review of the Literature Kathleen M. Mazor, EdD; Steven R. Simon, MD; Jerry H. Gurwitz, MD • Arch Intern Med. 2004;164:1690-1697. • Background  The objective of this study was to review the empirical literature on disclosure of medical errors with respect to • (1) the decision to disclose, • (2) the process of informing the patient and family, and • (3) the consequences of disclosure or nondisclosure. • Methods We searched 4 electronic databases … and [f]rom more than 800 titles reviewed, we identified 17 articles reporting original empirical data on disclosure of medical errors to patients and families.

16. . • Results  • … patients and the public support disclosure. Physicians also indicate support for disclosure, but often do not disclose. We found insufficient empirical evidence to support conclusions about the disclosure process or its consequences. • Conclusions  • Empirical research on disclosure of medical errors to patients and families has been limited, and studies have focused primarily on the decision stage of disclosure. Fewer have considered the disclosure process, the consequences of disclosure, or the relationship between the two. Additional research is needed….

17. Ben Kolb之死 • Ben Kolb, 7 years old, arrived at Martin Memorial Hospital, in Stuart, Fla., in December 1995. This was to be the third ear operation on the seven-year-old Ben. His doctor wanted to remove scar tissue that was left from the prior surgeries, at ages 2 and 5. • Ben was given general anesthesia, and about 20 minutes later it took full effect. His surgeon was handed what everyone thought was a syringe of lidocaine, a local anesthetic, which reduces bleeding. He injected it inside and behind Ben's ear. Moments later, for no apparent reason, Ben's heart rate and blood pressure increased alarmingly. Dr. George McLain, an anesthesiologist on standby for emergencies, was summoned. McLain helped to stabilize the child, but a short time later, Ben's heart rate and blood pressure dropped precipitously. For an hour and 40 minutes, frantic doctors performed CPR on the boy, knowing it was futile.

18. 醫師的眼淚 • More than a year later, the memories are fresh, and McLain sits at lunch, crying as he speaks. The other diners stare, but he makes no attempt to hide his tears. • How long would he have kept up the CPR? • "If it was my kid, I would want them to keep trying," he says. "I think we were never going to stop."

19. 告知不幸消息（What happened?) • Ben's heart did begin to beat again, and he was transferred to Martin Memorial's intensive care unit. • The surgeon, who knew Ben since he was a baby, we with McLain to talk to Tammy Kolb. "There has been a serious problem with your son," McLain remembers telling the woman. "His heart stopped. We had to restart his heart. He is extremely critical, in a coma-like state." • Ben remained in a coma for nearly 24 hours. His parents and older sister remained at his bedside as their fog and denial slowly lifted. The next day, they agreed that his ventilator should be removed, and he was declared brain dead.

20. 調查開始（What actually happen?) • First, the hospital's risk manager, Doni Haas, had all the syringes and vials used on Ben, locked away, then sent to an independent laboratory for analysis. • Second, Haas promised Ben's parents that she was going to find them an answer, if there was one." • There was. Tests showed that there had been a mix-up, a mistake, a human error in a system that made that error more likely. Ben Kolb, lab reports showed, was never injected with lidocaine at all. The syringe that was supposed to contain lidocaine actually contained adrenaline, a highly concentrated strength that was intended only for external use.

21. 何以錯誤會發生？ • Procedure in the Martin Memorial operating room at the time was for topical adrenaline to be poured into one cup, made of plastic, and lidocaine to be poured into a cup nearby, made of metal. The lidocaine syringe was then filled by placing it in the metal cup. It was a procedure used all over the country, a way of getting drug from container to operating table. • But it is a flawed procedure, the hospital learned. It allows for the possibility for the solution to be poured into or drawn out of the wrong cup. Instead, a cap, called a spike, could be put on the vial of lidocaine, allowing the drug to be drawn directly out of the labeled bottle and into a labeled syringe. The elimination of one step eliminates one opportunity for the human factor to get in the way.

22. 告知錯誤 • Haas received the lab results three weeks after Ben died. The family had hired and attorney by then, and Haas and McLain drove two hours and met with the Kolbs at Krupnick, Campbell, Malone, Roselli, Buser, Slama & Hancock. • A financial settlement was reached by nightfall, but neither side will confirm the amount paid to the Kolbs. • After the papers were signed, the family asked for a chance to talk to the doctors at the hospital. The first thing Ben's father, Tim, did when he entered the emotion-filled room was to hug his son's surgeon. Then came the torrent of questions, questions that had kept the Kolbs awake at night, questions they might never had been able to ask had the case spent years in court. • Was Ben scared when his heart rate started dropping? Was he in pain? How much did he suffer? • The doctors explained what the Kolbs did not know, that Ben had been put under general anesthesia long before anything went wrong.

23. How recurrence could be prevented?

24. 人性的挑戰 醫療錯誤的特性：很小的錯誤，很大的損害 告知錯誤的重要性 Do the right thing: 人性中本就有欺瞞、虛偽、逃避、推卸的傾向；這些不待學習。我們要學習的是誠實，誠實的認錯，誠實的面對認錯後的責任問題。

25. 醫療糾紛的道歉與認錯 對醫療糾紛解決之道的新思維

26. 正視醫療錯誤問題 • 醫學並非開啟廣大智慧之門，而是為無窮的錯誤設下界線。 • 醫學之進步乃是從犯錯開始 • 醫師所能犯的最大錯誤就在於其不認為自己會犯錯，因而沒有做好防備。

27. 醫療錯誤醫療傷害醫療糾紛之關係 • 　 無醫療傷害 　 　 無醫療糾紛 • 醫療錯誤　 醫療傷害　　 • 　　　 　　 醫療糾紛 • 司法途徑（上法院） 勝 • 敗 • 其他途徑

28. 發生醫療糾紛之後… • 第一時間影印病歷給病人，可能的話，給予解讀上的協助 • 主治醫師親自說明解釋，不要依賴社工人員 • 處理的過程中，要給予家屬受尊重的感覺 • 時間！時間！時間！ • 承諾未來品質的改善

29. 謝謝聆聽！