醫(yī)療糾紛之解決

醫(yī)療糾紛之解決第一頁，共29頁。Toallhealthcareprofessionalswhodidtherightthing,whendoingtherightthingwasveryverydifficult.

JohnBanjaMedicalErrorsandMedicalNarcissism第二頁，共29頁。Whatisrightinmedicalmalpracticecases?臺(tái)灣醫(yī)療糾紛爭訟中，病人敗訴率高醫(yī)界常見的說法：若該件事件，醫(yī)師有過失，早就理賠了；故上法院的案件中，本就是醫(yī)師沒有過失的情形居多質(zhì)疑：除非明顯過失，否則因?yàn)獒t(yī)療的高度專業(yè)性，一般人根本無從去爭執(zhí)醫(yī)師的過失。掩飾過失比承認(rèn)過失容易舉例：一婦產(chǎn)科醫(yī)師於接生後天忘記將置放於產(chǎn)婦陰道中的紗布取走，間隔達(dá)42天之久，但醫(yī)師仍振振有詞的主張，其有醫(yī)療之必要性。第三頁，共29頁。想想這些案例：小明放學(xué)後在家的附近和弟弟打棒球，弟弟投出一個(gè)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(shí)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(huì)教他怎麼作？第四頁，共29頁。案例二：李先生在經(jīng)過多年的辛勤工作後，存了一筆錢。他的願(yuàn)望就是將家中又窄又暗的小浴室改裝成五星級(jí)飯店般乾濕分離的豪華空間。經(jīng)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(fēng)過後，新浴室的馬桶卻不時(shí)的阻塞。找人檢修的結(jié)果是：當(dāng)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(huì)阻塞。李先生此時(shí)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。第五頁，共29頁。案例三甲為某大學(xué)的研究生，為賺取學(xué)費(fèi)下課後至麥當(dāng)勞打工，10點(diǎn)打烊後再回研究室作實(shí)驗(yàn)。某日半夜騎車返家的途中，因?yàn)樘^疲倦，一個(gè)閃神，輪胎似乎撞倒東西。下車一看，竟然有一個(gè)人倒臥血泊之中，其渾身酒氣沖天，但不幸已經(jīng)死亡。甲萬分驚恐，但並不明白究竟此一事件的原因?yàn)楹?？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(gè)屍體？此時(shí)夜深人靜，四下無人。甲相當(dāng)確定事發(fā)當(dāng)時(shí)沒有任何目擊證人。甲該怎麼作？第六頁，共29頁。案例四年輕的B小姐患有輕度精神分裂癥，並有自殺傾向。曾多次自殺，但都送醫(yī)急救後存活。一日深夜12點(diǎn)左右，B小姐打電話給家人，告知其在鄰近的公園，已經(jīng)吞食了200顆的安眠藥。家人聞?dòng)嵓泵小姐送往附近的H大醫(yī)院急診室。急診醫(yī)師趕忙替B小姐催吐，洗胃；過程中，因?yàn)锽小姐情緒激動(dòng)，所以用束縛帶將其固定在病床上，未料護(hù)士不注意，液體流入B小姐的氣管中，導(dǎo)致B小姐呼吸困難，進(jìn)而休克。雖急救後恢復(fù)生命跡象，5天後，B小姐死於吸入性肺炎。第七頁，共29頁。誠實(shí)最上策？前述四個(gè)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(rèn)為係爭當(dāng)事人之間正當(dāng)?shù)呐e動(dòng)是什麼？在一個(gè)公義的社會(huì)中，前4個(gè)案子應(yīng)該如何解決？第八頁，共29頁。為什麼認(rèn)錯(cuò)這麼難？歸咎文化使得認(rèn)錯(cuò)比文過飾非更困難Theoldparadigmofblamingandpunishingindividualsledtooverrelianceonflawlesspersonalperformanceandtothehidingofmistakesoutofshameandfeariftheyoccurred.AlbertWuconductedananonymousstudyof114houseofficersregardingtheirmostsignificantmistakes.Only54%haddiscussedtheirmistakewiththeirattendingphysician,andonly24%toldthepatientsandfamilies.WuAW.Dohouseofficerslearnfromtheirmistakes?JAMA.1991,265:2089-2094第九頁，共29頁。Patients'andPhysicians'AttitudesRegardingtheDisclosureofMedicalErrorsThomasH.Gallagher,MD;AmyD.Waterman,PhD;AlisonG.Ebers;VictoriaJ.Fraser,MD;WendyLevinson,MD

JAMA.

2003;289:1001-1007.

Context

…littleisknownabouthowpatientsandphysiciansthinkmedicalerrorsshouldbediscussed.Objective

Todeterminepatients'andphysicians'attitudesabouterrordisclosure.

Design,Setting,andParticipants

Thirteenfocusgroupswereorganized,including6groupsofadultpatients,4groupsofacademicandcommunityphysicians,and3groupsofbothphysiciansandpatients.Atotalof52patientsand46physiciansparticipated.第十頁，共29頁。.

Results

Patientswanteddisclosureofallharmfulerrorsandsoughtinformationaboutwhathappened,whytheerrorhappened,(x)howtheerror'sconsequenceswillbemitigated,andhowrecurrenceswillbeprevented.(x)Physiciansagreedthatharmfulerrorsshouldbedisclosedbut"choosetheirwordscarefully"whentellingpatientsabouterrors.Althoughphysiciansdisclosedtheadverseevent,theyoftenavoidedstatingthatanerroroccurred,whytheerrorhappened,orhowrecurrenceswouldbeprevented.

第十一頁，共29頁。錯(cuò)誤告知對(duì)醫(yī)病雙方的心理意義醫(yī)師的認(rèn)錯(cuò)與道歉對(duì)受到醫(yī)療傷害的病人而言，有治療上的意義，但是醫(yī)師們對(duì)未來醫(yī)療糾紛的恐懼使得他們傾向文過飾非。一個(gè)有害的錯(cuò)誤發(fā)生了，犯錯(cuò)的人自己也有心理上的創(chuàng)傷需要情緒支持，認(rèn)錯(cuò)，道歉，並得到病人的原諒對(duì)當(dāng)事醫(yī)師而言，也有治療的意義。病人原諒醫(yī)師對(duì)病人本身也有治療意義第十二頁，共29頁?，F(xiàn)狀的問題醫(yī)療機(jī)構(gòu)有提供專業(yè)服務(wù)與情緒支持，協(xié)助發(fā)生醫(yī)療錯(cuò)誤的醫(yī)師如何與病人溝通，討論錯(cuò)誤嗎？醫(yī)學(xué)教育有訓(xùn)練醫(yī)師，如何與病人溝通，討論錯(cuò)誤嗎？第十三頁，共29頁。Subtractinginsultfrominjury:addressingculturalexpectationsinthedisclosureofmedicalerror

NBerlingerandAWWu…whilephysiciansmayexpressaneedforself-forgivenessaftermakingerrorsandshouldbeawarethatpatientsmayalsorelyuponforgivenessasameansofdealingwithharm.…learninghowtodiscloseerrors,apologisetoinjuredpatients,ensurethatthesepatients’needsaremet,andconfronttheemotionaldimensionsofone’sownmistakesshouldbepartofmedicaleducationandreinforcedbytheconductofseniorphysicians.第十四頁，共29頁。CommunicatingWithPatientsAboutMedicalErrorsAReviewoftheLiterature

KathleenM.Mazor,EdD;StevenR.Simon,MD;JerryH.Gurwitz,MD

ArchInternMed.

2004;164:1690-1697.Background

Theobjectiveofthisstudywastoreviewtheempiricalliteratureondisclosureofmedicalerrorswithrespectto(1)thedecisiontodisclose,(2)theprocessofinformingthepatientandfamily,and(3)theconsequencesofdisclosureornondisclosure.Methods

Wesearched4electronicdatabases…and[f]rommorethan800titlesreviewed,weidentified17articlesreportingoriginalempiricaldataondisclosureofmedicalerrorstopatientsandfamilies.第十五頁，共29頁。.

Results

…patientsandthepublicsupportdisclosure.Physiciansalsoindicatesupportfordisclosure,butoftendonotdisclose.Wefoundinsufficientempiricalevidencetosupportconclusionsaboutthedisclosureprocessoritsconsequences.Conclusions

Empiricalresearchondisclosureofmedicalerrorstopatientsandfamilieshasbeenlimited,andstudieshavefocusedprimarilyonthedecisionstageofdisclosure.Fewerhaveconsideredthedisclosureprocess,theconsequencesofdisclosure,ortherelationshipbetweenthetwo.Additionalresearchisneeded….第十六頁，共29頁。BenKolb之死BenKolb,7yearsold,arrivedatMartinMemorialHospital,inStuart,Fla.,inDecember1995.Thiswastobethethirdearoperationontheseven-year-oldBen.Hisdoctorwantedtoremovescartissuethatwasleftfromthepriorsurgeries,atages2and5.Benwasgivengeneralanesthesia,andabout20minuteslaterittookfulleffect.Hissurgeonwashandedwhateveryonethoughtwasasyringeoflidocaine,alocalanesthetic,whichreducesbleeding.HeinjecteditinsideandbehindBen'sear.Momentslater,fornoapparentreason,Ben'sheartrateandbloodpressureincreasedalarmingly.Dr.GeorgeMcLain,ananesthesiologistonstandbyforemergencies,wassummoned.McLainhelpedtostabilizethechild,butashorttimelater,Ben'sheartrateandbloodpressuredroppedprecipitously.Foranhourand40minutes,franticdoctorsperformedCPRontheboy,knowingitwasfutile.第十七頁，共29頁。醫(yī)師的眼淚Morethanayearlater,thememoriesarefresh,andMcLainsitsatlunch,cryingashespeaks.Theotherdinersstare,buthemakesnoattempttohidehistears.HowlongwouldhehavekeptuptheCPR?"Ifitwasmykid,Iwouldwantthemtokeeptrying,"hesays."Ithinkwewerenevergoingtostop."第十八頁，共29頁。告知不幸消息（Whathappened?)

Ben'sheartdidbegintobeatagain,andhewastransferredtoMartinMemorial'sintensivecareunit.Thesurgeon,whoknewBensincehewasababy,wewithMcLaintotalktoTammyKolb."Therehasbeenaseriousproblemwithyourson,"McLainrememberstellingthewoman."Hisheartstopped.Wehadtorestarthisheart.Heisextremelycritical,inacoma-likestate."

Benremainedinacomafornearly24hours.Hisparentsandoldersisterremainedathisbedsideastheirfoganddenialslowlylifted.Thenextday,theyagreedthathisventilatorshouldberemoved,andhewasdeclaredbraindead.第十九頁，共29頁。調(diào)查開始（Whatactuallyhappen?)First,thehospital'sriskmanager,DoniHaas,hadallthesyringesandvialsusedonBen,lockedaway,thensenttoanindependentlaboratoryforanalysis.Second,HaaspromisedBen'sparentsthatshewasgoingtofindthemananswer,iftherewasone."

Therewas.Testsshowedthattherehadbeenamix-up,amistake,ahumanerrorinasystemthatmadethaterrormorelikely.BenKolb,labreportsshowed,wasneverinjectedwithlidocaineatall.Thesyringethatwassupposedtocontainlidocaineactuallycontainedadrenaline,ahighlyconcentratedstrengththatwasintendedonlyforexternaluse.第二十頁，共29頁。何以錯(cuò)誤會(huì)發(fā)生？ProcedureintheMartinMemorialoperatingroomatthetimewasfortopicaladrenalinetobepouredintoonecup,madeofplastic,andlidocainetobepouredintoacupnearby,madeofmetal.Thelidocainesyringewasthenfilledbyplacingitinthemetalcup.Itwasaprocedureusedalloverthecountry,awayofgettingdrugfromcontainertooperatingtable.Butitisaflawedprocedure,thehospitallearned.Itallowsforthepossibilityforthesolutiontobepouredintoordrawnoutofthewrongcup.Instead,acap,calledaspike,couldbeputonthevialoflidocaine,allowingthedrugtobedrawndirectlyoutofthelabeledbottleandintoalabeledsyringe.Theeliminationofonestepeliminatesoneopportunityforthehumanfactortogetintheway.第二十一頁，共29頁。告知錯(cuò)誤HaasreceivedthelabresultsthreeweeksafterBendied.Thefamilyhadhiredandattorneybythen,andHaasandMcLaindrovetwohoursandmetwiththeKolbsatKrupnick,Campbell,Malone,Roselli,Buser,Slama&Hancock.Afinancialsettlementwasreachedbynightfall,butneithersidewillconfirmtheamountpaidtotheKolbs.

Afterthepapersweresigned,thefamilyaskedforachancetotalktothedoctorsatthehospital.ThefirstthingBen'sfather,Tim,didwhenheenteredtheemotion-filledroomwastohughisson'ssurgeon.Thencamethetorrentofquestions,questionsthathadkepttheKolbsawakeatnight,questionsthey