Author: Medical Law Exchange
Reprint please indicate the source: Medical Law Hui WeChat public account
The patient Mr. Li (23 years old), 4 years ago, developed mucus-removing thick stools without obvious incentives, accompanied by paroxysmal pain and discomfort in the left lower abdomen, and was diagnosed with ulcerative colitis by the city hospital After repeated colonoscopy, the diagnosis of ulcerative colitis was confirmed, and drug maintenance treatment such as sulfasalazine (SASP) was given, and the condition had repeated.
This time, she was admitted to the city hospital again due to “repeated mucus removal for more than 4 years and another 10 days”, and the initial diagnosis was ulcerative colitis. Gastroscopy results showed: chronic superficial gastritis, duodenitis. On the 15th day of admission, the patient’s abdominal MRI and abdominal three-dimensional radiograph showed intestinal obstruction. The surgical consultation considered the possibility of paralytic intestinal obstruction. Due to the poor general condition of the patient, conservative treatment was recommended first, and the patient’s family requested to be transferred.
The next day, the patient was transferred to the provincial hospital for treatment. The initial diagnosis was: incomplete intestinal obstruction; ulcerative colitis; toxic megacolon? Myelosuppression. On the 4th day of admission, the patient had peritoneal irritation and underwent emergency exploratory laparotomy. During the operation, dilatation, edema, gas and fluid accumulation of the whole small intestine were found, especially the proximal small intestine dilatation, but no obvious organic obstruction was found in the whole small intestine. , The surface of the entire small intestine is mottled, mainly at the proximal end, with subserosa hemorrhage, multiple pinpoint-like necrosis, and two perforations of about 2 mm in diameter in the small intestine 200cm away from the ileocecal valve. A loop ostomy was performed outside the small intestine. Pathological diagnosis: The small intestinal wall tissue showed extensive congestion and edema, a large number of acute and chronic inflammatory cell infiltration with hemorrhage and multifocal slit-like ulceration and vasculitis, and its tissue morphology suggested inflammatory bowel disease. Variety.
After the operation, the patient’s condition continued to worsen with severe infection, and died after rescue failure. The final diagnosis: diffuse necrotizing enterocolitis; ulcerative colitis; bone marrow suppression; multiple organ failure .
The patient’s family believes that the municipal hospital is irresponsible, misdiagnosed and mistreated, which seriously delayed the treatment of the patient’s condition, resulting in his death, and sued the municipal hospital for compensation for various losses totaling more than 990,000 yuan .
The Municipal Medical Association identified that: the medical prescription had a basis for the diagnosis of “ulcerative colitis” and “incomplete intestinal obstruction”, and the treatment and corresponding treatment did not violate the medical principles. The clinical manifestations of diffuse necrotizing enterocolitis in the patient are not typical, and there is no obvious indication for surgery. It is difficult for doctors to make a clear diagnosis before surgery and pathological examination. In the process of diagnosis and treatment, the doctor had insufficient communication with the patient, and the relevant examinations were not completed in time. There were defects, but there was no causal relationship with the death of the patient. The patient refused to accept it and applied to the Provincial Medical Association for identification.
Provincial Medical Association identified that: 1. The doctor underestimated the severity of the patient’s condition and the rapid progress of the disease, and the relevant inspection data were not timely and insufficient. The causes of adverse events were analyzed, and the diagnosis of intestinal obstruction was not performed until 15 days after admission to the hospital after performing abdominal plain film and MR examination; the first disease course record and the superior physician’s ward round record considered the need for colonoscopy review or capsule endoscopy, but always It was not implemented, but insisted that the patient’s physical condition was poor and the risk of colonoscopy was high, and family members did not consider re-examination of colonoscopy for the time being (the patient denied this opinion and request during the on-site investigation, and there was no such content and the patient’s opinion in the doctor-patient communication record. ).
2. The doctor did not carefully observe the patient’s condition, and the medical record was not complete enough. The patient has a long course of disease and a serious condition. When the hospitalization treatment effect is not obvious and the condition is aggravated, the serious condition of the patient may be complicated by intestinal obstruction. , The patient was not notified of severe or critical illness in time, and the patient was hospitalized for 16 days, with only 8 records of the course of the disease, and the important abdominal signs were always described in a copy style, lacking the real clinical signs.
3. The communication between the doctor and the patient is not in place. During the hospitalization of the patient, when the patient is in a critical condition and the treatment effect is not effective, the doctor fails to objectively fulfill the condition, diagnosis, treatment and prognosis to the patient. inform. There is a certain causal relationship between the fault in the medical behavior of the doctor and the death of the patient, and its causal force is a secondary factor.
The court of first instance decided that the city hospital should bear 40% of the responsibility based on the medical damage appraisal report of the Provincial Medical Association, and compensated the patient for various losses totaling more than 380,000 yuan.
The city hospital refused to accept it and filed an appeal. The court of second instance dismissed the appeal and upheld the original judgment.
The medical records are the records and summaries of the whole process of diagnosis and treatment of patients by medical staff. They are the most important basis for determining the facts of a case and clarifying responsibilities. Medical record writing refers to the behavior of medical personnel to obtain relevant information through medical activities such as consultation, physical examination, auxiliary examination, diagnosis, treatment, and nursing, and to summarize, analyze, and organize medical activity records. fault and liability.
In trial practice, failure to pay attention, delay in treatment, and failure to notify are the main reasons for medical institutions to assume responsibility for medical damage.
The duty of care of a medical institution means that medical staff should have a high degree of attention in medical activities, including attention to changes in patients’ conditions, attention to diagnosis and treatment methods, attention to surgical operations, etc., to avoid The patient suffers undue danger or damage occurs. In this case, the patientHe has visited the city hospital for many times. When the patient’s hospitalization treatment effect is not obvious and the patient’s condition is aggravated, the city hospital does not organize the discussion of difficult cases, does not invite in-hospital or out-of-hospital experts for consultation in time, and fails to notify the patient of serious or critical illness in time. In addition, the abdominal plain film and MR examination were only performed 15 days after the patient was admitted to the hospital, which obviously violated the provisions of the core system of medical quality and safety, and was therefore found to be at fault by the court.
The duty of disclosure of a medical institution comes from the patient’s right to informed consent, which means that medical staff shall truthfully inform the patient of the condition, medical measures, medical risks, etc., to the patient during the diagnosis and treatment activities, and obtain their expressly agree. If medical personnel fail to fulfill their obligation to inform and cause damage to patients, the medical institution shall be liable for compensation. In this case, the medical records of the city hospital recorded that “the family members do not consider re-examination of colonoscopy for the time being”, but the on-site investigation patient denied this opinion and request, and there was no such content and the patient’s opinion in the doctor-patient communication record. According to the principle of proof in civil litigation, the municipal hospital needs to provide evidence for its views. This inspection is of positive significance for identifying the patient’s condition as soon as possible. However, there is no relevant notification record in the medical records, and when the patient’s condition is critical and the treatment effect is not effective, Neither the patient’s condition, diagnosis, treatment, and prognosis were objectively informed to the patient, nor a critical illness notice was issued to the patient, which was found by the court to be at fault.
In addition, after the patient is admitted to the hospital, the medical institution should keep a continuous record of the patient’s condition and the diagnosis and treatment process, that is, the disease course record, which includes the patient’s condition change, important auxiliary examination results and clinical Significance, superior physician’s ward round opinion, consultation opinion, physician’s analysis and discussion opinion, diagnosis and treatment measures taken and their effect, preoperative discussion record, first postoperative course record, important matters notified to patients and their close relatives, etc.
According to regulations, the first disease course record should be completed within 8 hours after the patient is admitted to the hospital; the daily disease course record should not be recorded once more than 3 days at the most, and the critically ill patient should write the disease course record at any time according to the change of the condition, every day At least 1 time, the recording time is specific to the minute, and for severely ill patients, the disease course record should be recorded at least once every 2 days. In this case, the patient was hospitalized for 16 days, during which the city hospital conducted ward rounds, surgical consultation, gastroscopy, abdominal plain film and MR examination. Only 8 records of the course of the disease were unreasonable, and the important abdominal signs were described in copy form. Inconsistency with the patient’s condition and vital signs, not only violated the provisions of medical record writing, but also violated the core system of medical quality and safety, so the court found fault.
Every illegal diagnosis and treatment behavior may bring great pain to the patient’s body and spirit, and even cause the patient to lose their life, thereby aggravating the contradiction between doctors and patients. Therefore, medical institutions and their medical staff Personnel should exercise a high degree of duty of care and duty to inform and explain in the diagnosis and treatment activities, pay close attention to the changes in the patient’s condition, practice in accordance with laws and regulations, and ensure the safety of patients.
(This article was originally written by the Medical Law Institute, adapted from a real case, using a pseudonym to protect the privacy of the parties)