How to minimise medical negligence or error

by Dr K. M. Wasantha Bandara

This is a humble effort to build up on the article titled, ‘Medical negligence or error’, published in The Island on 18th July. The author of the article, Professor Susirith Mendis, who is a well reputed medical professional and an academic, has drawn our insight into unfortunate events taking place in the health system. That is very important at this time, because certain sections in the society are trying to insult and disintegrate our health system, obviously for narrow, political gains. As Prof. Mendis has emphasised it is an accepted fact worldwide that medical errors and negligence do occur in any system, although there is lack of information except for emblematic cases like the death of a young girl. However, in my opinion, any citizen may have a right to criticize any undesirable event, taking place in the process of delivery of healthcare to people, but it is very unfair to undermine the public confidence in the system. That is because our health system is considered to be Noble in terms of equity and geographical and financial access, when compared with so-called systems in most parts of the world.

I am sure there will be no one in our country to challenge the credentials of Professor Mendis to give a learned opinion on the issue. While being very much grateful and thankful to him, I must apologise to him for presenting my credentials to add some thoughts to his work as to how to minimise such incidents in the future. I am a dental surgeon who has postgraduate qualifications in three different fields, namely, Health Systems Management, Financial Management and Quality Management. I was certified as a quality manager in health care in New Zealand, and also have more than eight years of experience as a health programme manager overseas, including in certain projects funded by WHO and UNICEF. I also have participated in a number of international workshops designed to train “economic hit men” who are used to promote subtle strategies to expand the healthcare market in the name of improving the quality of care.

As such, I have personally experienced sinister attempts to disintegrate public funded health systems in favour of markets. There was one thing common in those attempts, which is what we see in our country today. These days, the attack on healthcare systems is much easier because of Zuckerberg’s army of mental slaves who can be used for the purpose free of charge. We also have experienced the role played by them to pave the way for regime change in the name of system change in Sri Lanka. The other feature which is common in these sinister attempts in exaggeration of undesired outcomes is willful cover-up of actual reasons for poor performance of the system. However, in my opinion unethical, unaccounted and corrupt practices of doctors and medical administrators do more harm to the system than errors or negligence. For example, prescribing habits of the majority of doctors are influenced by commercial interests of pharmaceutical companies, leading to over use and irrational use which is a cost to the patient as well as the nation. The corrupt practices of medical administrators in the procurement process of pharmaceuticals have undermined public confidence in the system.

I also have contributed to a research project where legal frameworks governing the healthcare delivery systems in 40 countries, including Sri Lanka, were studied. That was about more than 25 years back, and I was proud to be a Sri Lankan among western colleagues, because our system was considered to be one of the best, in terms of equity, geographical and financial access, responsiveness and relative cost of care or in other words efficiency versus effectiveness. It was also understood that remarkable performances in our health system can be attributed to free education, and civilizational inheritance, where empathy and kindness are guiding principles in social interaction in our country. Anyway, it is a fact that our people have enjoyed free healthcare, and free education ever since the origins of our civilisation.

It is obvious that we as a nation were able to achieve excellence in key aspects in our system, because of the national policy of free healthcare and hard work of health administration we had in the 70s and 80s. When compared with today’s administrative structure and the administrators themselves, the excellence of the old generation is well proved, although at that time they had no postgraduate qualifications in management, but professionalism and humanism. They took great pain amidst all constraints, especially lack of available resources, to build a system that was so effective and efficient to a level to be admired in international forums. Unfortunately, today’s generation of administrators, having postgraduate qualifications, training, and a comfortable lifestyle, have failed to uphold what their Predecessors built at difficult times than today in terms of resources. Anyway, one must be fair by accepting the fact that generational gap or deterioration of social and professional values in our society may have contributed to overall degeneration of the values in the health system.

As Professor Mendis has mentioned, and I have pointed out above, Zuckerberg’s army contributes to further deterioration of the system by posting irresponsible and indiscriminate comments in social media. In our country, although we have 6 million households, there are 8 million social media accounts and as such, there is a reasonable leverage to manipulate social opinion, and thereby social systems by a centralised system operated by external forces.

However, I will not go into details of how medical negligence or errors take place in the system, since Professor Mendis has dealt extensively on that aspect, I would like to draw the attention of the administrators and the public on the aspects of how to prevent or minimise them. Irrespective of the fact, whether the issue is negligence, error, or a kind of contributory, negligence or error, for which patients are also responsible partly or unpredictable mishap, medication error, Or poor reconciliation of medications prescribed by multiple specialists independently of each other or whatever other undesired outcome; definitely there will be a certain degree of dispute between the provider of the service and the recipient.

If the dispute is not managed properly, a minor negligence can be interpreted as criminal negligence will lead to litigation, creating more problems in the system. In the USA, it is well known that there are legal firms spying on undesirable events, taking place in hospitals and offering litigation services on the basis of sharing the compensation equally. This situation has led to unnecessary investigations and other defensive actions by the medical professionals and finally extra cost to the patient as well as the nation. That is the main reason why the US is classified as the highest spender on healthcare with poor outcomes. Healthcare spending in the US is amounting to 13.5% of the GDP, although 20 million people have no insurance cover at all for healthcare and for those who have insurance the overhead or the cost of insurance is 35%, which does not cover the cost of care.

To cut it short to be fair with The Island newspaper, which is always open for discussion, on issues of national importance, I would like to present in point form as to how to prevent or minimise undesirable outcomes in a system. Irrespective of the underlying cause of the poor outcome in the system, we could categorise those remedial measures into threefold. The first and foremost is protection of the noble fundamentals of the system, where equity, geographical and financial access is guaranteed and cost of care is contained to have justifiable balance between the efficiency and the effectiveness. People must be aware of subtle strategies, introduced to address the issue of being responsive to the expectations of the people, and finally how they facilitate expansion of the healthcare market, depriving sections of the society of basic care.

One of those subtle strategies recommended by international funders, is to divide or split the funder and provider. For example, at present, both the funder and the provider are department health, whereas if those functions are separated public and private providers have equal access to the public funds. If that is facilitated by insurance, 35% of the funds will be wasted as insurance admin cost or overhead. However, there is a need and an opportunity to improve the system further, mainly by addressing interconnected issues in the present system. One is the continuity of care and the other is a referral mechanism for specialist care, both of which can be addressed by establishing a General Practice sub system integrating the public and private out patient care.

The second approach to minimize undesirable outcomes is strengthening of legal frameworks to regulate medications, devices-etc., and to improve the accountability of medical manpower, as well as prevention and settlement of disputes. It is obvious that doctors individually cannot guarantee the safety and efficacy of medications and medical devices they are supposed to use and as such the NMRA act should provide for that. But in the present wave of allegations and counter allegations, the need to amend and strengthen the legal framework is not highlighted.

Although the draft of the amended act is in the drawers without being presented to cabinet and Parliament. Obviously, it is a well-known fact that the so -called pharmaceutical mafia takes decisions over and above the politicians and officials. That is the very reason as to why state pharmaceutical corporation is reluctant to intervene in the market to bring down the prices of essential drugs, which is contrary to principles of its founder Prof. Senaka Bibile. Also, countries like New Zealand have an independent body called health and liability commissioner established by law to intervene and settle the disputes as a mediator and to improve the accountability of medical personnel. But unfortunately, that kind of third-party approach to minimize disputes and public unrest as well as need for litigation is not discussed in the noise created by various interested parties. When there is a permanent independent mechanism established by law, it is not easy for interested parties to undermine the confidence of the people in the system.

The third approach is to improve, modify or optimize the knowledge, skills and behavioral aspects of the key healthcare personnel, for which multiple strategies can be used, including strengthening of clinical processes and practices as well as changing of management culture. There is a long list of interventions to that effect with evidence which can be easily applied in our system. Even simple measures like multidisciplinary ‘grand ward rounds’, case reviews, death reviews, medical audits in emblematic cases, and related clinical or process audits to identify common weaknesses would make a big change in the minds of the medical manpower. There is very remarkable evidence of improvements achieved by way of introducing complaint and incident registers with transparent inquiry and reporting mechanisms. Also, introducing protocols and practice guidelines to guide and unify practices that can lead to questionable outcomes have shown remarkable results.

Besides, in order to restore the public confidence a comprehensive financial and quality audit must be done to identify the weaknesses and corrupt practices in relation to registration and procurement of pharmaceuticals. It should also be mentioned that prices of medicine cannot be reduced only by price controlling mechanisms alone. In the present economic crisis, the US dollar went up by less than 50%, yet the prices of essential medicines went up in a range of 80% to 300%. Those greedy pharmaceutical traders must be countered by adequate market intervention by the state pharmaceutical corporation, which was created by Professor Senaka Bibile, for that purpose.

 But, unfortunately, none of these remedial actions to improve and protect the system is not discussed by the medical associations and trade unions, except for individuals like Professor Mendis. If the fundamentals of discussion on this matter is not corrected, it can be predicted that we would get a “Gota go home – Ranil come back” type of solution to the problem.