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ELL 4
TH
edition
 First on the medical side
 Beyond Davangere
 ELL think tank
 ELL Co-ordinators
 ELL For People
Reach out to all
stakeholders
SOCIAL CHANGE
THROUGH
KNOWLEDGE
Based on academics
BUT NOT AN
ACADEMIC LECTURE
Knowledge unites like
nothing else
A life beyond
boundaries
OUR HEALERS
GODS
ON
EARTH
Declaration
I solemnly pledge myself to consecrate
my life to the service of humanity.
Even under threat, I will not use my
medical knowledge contrary to the laws
of humanity.
Declaration

I will maintain the utmost respect for human life
from the time of conception

I will not permit considerations of religion,
nationality, race, party politics, or social
standing to intervene between my duty and my
patient
Declaration

I will practice my
conscience and dignity
profession
with

The health of my patient will be my
first consideration

I will respect the secrets which are
confided in me
Declaration

I will give to my teachers the
respect and gratitude which is their
due

I will maintain by all means, the
honour and noble traditions of the
medical profession

I will treat my colleagues as my own
brothers
The “Swiss
Cheese” Model of Accident Causation (Reason, 1990)
Excessive cost cutting – staffing reduction
Equipment shortages
Leadership
Communication
“Latent Errors”
 Staff Motivation
 Divided or confused accountability
 Poor compliance to policies
Policies/
Procedures
 Poor Coordination & Communication
Available
Resources
Barriers
to
Accidents
Deficient training program
Inexperienced X-Ray Tech
Failed to review allergies
Communication
Wrong X-ray marker used
Wrong procedure performed
Accident & Injury
Failures in the
System
Wrong Site Surgery
 Medication Error
 Fall
Ethikos for Medicos
Structure
 Ethics
 Conduct
 Medical negligence
 Legal status
 Quality standards
 Conclusion
Medical ethics
 Medical ethics is a system of moral principles that
apply values and judgments to the practice of
medicine
 As
a
scholarly
encompasses
its
discipline,
practical
medical
application
in
ethics
clinical
settings as well as work on its history, philosophy,
theology, and sociology
Medical Universe
Patient At The Center
Medical Ethics
History
 Duty of physicians in antiquity – Hippocratic Oath
 First code of medical ethics –Formula Comitis
Archiatrorum published in 5th Century
 Medieval/Early Modern Period – Ishaq bin Ali
Rahawi – Code of a Physician
 18th/19th Centuries – Thomas Percival – first
modern code on Medical Ethics -1794
 Expanded in 1803, coined the expressions
Medical Ethics
History…
Expanded in 1803, coined the expressions “medical
ethics” and “medical jurisprudence”
 In
1847,
the
American
Medical
Association
adopted its first code of Ethics, with this based on
large part upon Percival’s work
Medical ethics
Ethics is a voluntarily self-imposed code
of conduct by the medical profession.
Values
in
Medical Ethics
Common framework – four principals approach by
Tom Beauchamp and James Childress in their book
Principles of biomedical ethics
Values
in
Medical Ethics
Respect for autonomy – patient
has the right to choose or refuse
their treatment
Values
in
Medical Ethics
Beneficence
–
a
practitioner
should act in the best interest of
the patient
Values
in
Medical Ethics
Non – maleficence –”first, do no
harm”
Values
in
Medical Ethics
Justice-concerns the distribution
of scarce health resources, and
the decision of who gets what
treatment (fairness and equality)
Values
in
Medical Ethics
Other Values
 Respect for persons – the patient have
the right to be treated with dignity
 Truthfulness and honesty – the concept
of informed consent
Values
Autonomy
 Rights of individuals to self
determination
 Outcomes that are important to
patients
 “Paternalistic” tradition within
healthcare
Values
Autonomy...
Respect for autonomy is the basis
for informed consent and advanced
directives
 Autonomy is a general indicator
of health
Values
Beneficence
 Actions that promote well being
of others
 Taking actions that serve the
best interest of the patients
 One of the core values of
healthcare ethics
Values
Non-Maleficence
 “First, do no harm”
 Enthusiastic practitioners – “ the
treatment was a success, but the
patient died”
 Non-maleficence is not absolute,
balances against beneficence, together
double effect
Values
Double Effect
 Double effect refers to two types of
consequences which may be produced by
a single action and in medical ethics it
is usually regarded as the combined
effect of beneficence and nonmaleficence
 Morphine as an example
Values
Double Effect
 Autonomy can come into conflict with
beneficence when patients disagree with
the recommendations that the
healthcare professionals believe are in
the patient’s best interest
On the other hand, autonomy and
beneficence/non-maleficence may also
overlap
Values Euthanasia
Aruna Ramchandra Shanbaug vs the
Union of India.
Most famous Indian case on this
subject.
Since 1973 in persistent vegetative
state.
In KEM hospital since then
Values
Euthanasia...DEAN
 This one is the finest example of
love, professionalism, dedication &
commitment
 Mature society – capacity and
commitment to take care of its “invalid
ones”
 Society not matured for Mercy Killing
Values
Euthanasia...DEAN
It may get misused and our
monitoring and deterring
mechanisms may fail to prevent
those unfortunate incidences
Values
Euthanasia...
WITHDRAWL OF LIFE SUPPORT
SYSTEMS OF A PATIENT IN
PERMANENT VEGETATIVE
STATE, PVS.
Article 226 of the Constitution, HC
Ethics
Informed Consent
Usually refers to the idea that a
person must be fully informed
about and understand the potential
benefits and risks of their
treatment
Ethics
Confidentiality

Confidentiality is commonly applied to
conversations between doctors and patients
 Concept of patient-physician privilege
 Confidentiality is challenged in sexually
transmitted disease and in pregnancy in an
underage patient cases
Traditionally, confidentiality has been viewed
as a relatively non-negotiable tenet of
medical practice
Ethics
Other issues

Communications – when not proper
 Declaration of Helsinki regarded as
authoritative in human research issues
 Referral – Doctors who receive income from
referring patients for medical tests
 Fee splitting and payments of commissions
to attract referrals of patients is considered
unethical and unacceptable in most parts of
the world.
Ethics
Other issues
Vendor Relationships
 Sexual Relationships
 Futility- no chance for a patient to
survive. Also called non-beneficial care
 Substituted Judgement
Conduct
 Indian Medical Council Act 1956
 Functions – Medical Register, Medical
Education, Recognition of Foreign Medical
Qualifications, Appeal against DA, Warning
notice, Declaration of Geneva
Serious Professional
Misconduct
 Adultery
 False and misleading certificates
 Dichotomy or fee splitting
 Covering i.e. assisting someone who has no
medical qualification
 Advertising
Conduct
Indian Medical Council (Professionals Conduct,
Etiquette and Ethics) Regulations, 2002
Rights of Medical Practitioners
 right to practice medicine
 right to choose a patient
 right to dispense medicines
 right to possess and supply dangerous drugs
to his patients
 right to add titles to his name
 right to recovery of fees
Conduct
Duties of Medical Practitioners
 Duty to exercise a Reasonable Degree of
Skill and knowledge
 Duties with regard to attendance and
examination
 Duties to furnish Proper and Suitable
medicines
 Duty to give instructions
 Duty to control and warn
 Duty to Third Parties
Conduct
Duties of Medical Practitioners







Duty to inform patient of risks
Duty with regard to poison
Duties with regard to operations
Duty to notify certain diseases
Duty with regard to Consultation
Professional Secrecy
Privileged communication
Conduct
Duties of Patient
 Duty to provide complete
information/history/facts
 Duty to follow instructions of Doctor
 Duties to pay reasonable fee to the Doctor
Conduct
Rights of Patients
 CHOICE – of Doctor
 ACCESS - to healthcare facilities
 DIGNITY – to be treated with care and
compassion
 PRIVACY – to be treated in privacy
 CONFIDENTIALITY
 Right to know
 REFUSAL
Conduct
Rights of Patients






SECOND OPINION
RECORDS
CONTINUITY
COMFORT
COMPLAINT
COMPENSATION
Conduct
MEDICAL RECORDS –Where we fail?
1)Basis for patients care and for
continuity in the evaluation of patients
treatment
2)To serve as documentation for
reimbursement
3)To provide data for in medical
education and clinical research
4)To assist in protecting legal rights of
all – patient, doctor etc
Conduct
MEDICAL RECORDS –Where we fail?
5) To follow up the patients, evaluation of
drug therapy and cost accounting
6) Medical records are needed in cases of
professional negligence, for payment of third
party payment in health and accident
insurance, life insurance policies, policies of
disability, accidental deaths, traffic accidents
etc
Medication-Use System
Prescribing
Dispensing
Administration
Medication Error
Medication error leading to the death or serious
disability of patient due to incorrect administration
of drugs, for example:
 Omission error
 Dosage error
 Dose preparation error
 Wrong time error
Medication Error
 Wrong rate of administration error
 Wrong administrative technique error
 Wrong patient error
 Patient death or serious disability associated
with
an
avoidable
delay
in
treatment
response to abnormal test results
or
Measures to prevent
medication errors
 Develop and Follow Drug Formulary
 Standardize Brands – In patients
 Electronic
Prescriptions/Requisitions
–
Remove
Typo
errors
 Use latest technology like Bar Coding / RFID
 Avoid verbal orders – Insist for written orders
 Separate products that look alike – Use labeling / colour
coding
 Dispense every medication in different pack with proper
labeling
Conduct
Physician – Patient Relationship
THERAPEUTIC RELATIONSHIP
 FORMAL RELATIONSHIP
PROFESSIONAL MISCONDUCT
(INFAMOUS CONDUCT)
(ETHICAL MAL-PRACTICE)
Definition- “ It is any conduct of the doctor
which might be reasonably regarded as
DIS-GRACEFUL, & DIS-HONOURABLE,
and the conduct is judged by professional men of
good repute and competence”.
PROFESSIONAL MISCONDUCT
PROFESSIONAL MISCONDUCT
PROFESSIONAL MISCONDUCT
PROFESSIONAL MISCONDUCT
PROFESSIONAL MISCONDUCT
PROFESSIONAL MISCONDUCT
PROFESSIONAL MISCONDUCT
PROFESSIONAL MISCONDUCT
PROFESSIONAL MISCONDUCT
PROFESSIONAL MISCONDUCT
PROFESSIONAL MISCONDUCT
PROFESSIONAL MISCONDUCT
PROFESSIONAL MISCONDUCT
PROFESSIONAL MISCONDUCT
Communication
Communication
 “Communication Age”
 Medical practice depends upon doctor – patient
encounter.
 Relevant information for proper diagnosis &
care
 Ensure patient co-operation and compliance
Communication
The Issues
 Very few people belonging to the medical
fraternity are brilliant as well as convincing
conversationalists
 Most of them are poor writers and many do
not like to write
 Poor listening skills, physician interrupts a
patient during the encounter every eighteen
seconds
Communication
 Clarity is the hallmark of all doctor-patient
communication
 Good
communications
skills
have
shown
to
increase patient’s cooperation
 Famous heart surgeon from Houston
 Most patients are too embarrassed to ask the
physician to repeat an instruction
Communication
Communication skills plays major role in
 taking appropriate/relevant history
 educating patient about his condition
 discussing his prognosis
 justifying treatment plan
 preparing him mentally to undergo surgery
Communication
Medical care is increasingly fragmented
 no longer long association with single physician
 Lack
of
appropriate
verbal
interaction
follow through medical advice lead to
1)24% patients being grossly dissatisfied
2)38% moderately compliant and
3)11% non-compliant
and
Communication
Strategies for Teaching Medical Communication
Skills
 Rapport building
 Agenda setting
 Information management
 Active listening for respondents
 Responding to emotions
 Skills in reaching common grounds
Negligence
“Negligence is the breach of a duty caused by omission
to do something which as reasonable man, guided by
those
considerations
which
ordinarily
regulate
the
conduct of human affairs would do, or doing something
which a prudent and reasonable man would not do”
l
Negligence
Current forensic speech, negligence has three
meanings. They are:
 a state of mind
 careless conduct
 the breach of duty to take care that is
imposed by either common or statute law
 Essential components are duty, breach and
resulting damage
l
Negligence
Professional Negligence
 Due Care – It means such reasonable care and
attention of patient as their mental and physical
condition may requires
 Civil Negligence – Patient or relative bring a
civil suit for getting compensation
 Liability for Negligence – Duty, Dereliction,
Direct Causation and Damage
l
Negligence
Instances
of Professional Negligence
 Refusal when urgent hospitalization required
 Failure of obtain informed consent
 Failure to examine patient himself
 Failure to inform the risk of refusal of
treatment
 Not ordering X-ray examination
 Not reading X-ray properly
 Failure to attend patient on time
 Failure to keep well informed of the
advances of medical science
l
Negligence
Instances
of Professional Negligence
 Failure to give post operative care
 Failure of get consultation wherever
required
 Experimentation on patient without
consent
 Prescribing a drug which has resulted
in adverse reaction earlier
l
Negligence
Contributory Negligence
Unreasonable conduct or absence of
ordinary care on the part of the
patient/attendant, which combined with
doctor’s negligence contributed to the
injury complained of, as a direct
proximate cause and without which the
injury would not have occurred
j
Negligence
Generally speaking, it is the amount of damages
incurred which is determinative of the extent of
liability in tort; but in criminal law it is not the
amount of damages but the amount and degree of
negligence that is determinative of liability
Negligencej –Mens rea
 Mens rea is essential ingredient of criminal
negligence
 Acting ‘recklessly’ before the act, he fails to
give any thought to he possibility of there being
such an risk or having recognized went ahead to
do that.
 Rashness to a degree to take an hazard where
such an injury is imminent
Negligencej –Grossness
 Factor of grossness or degree does assume
significance
 Negligence action in tort and negligence action
punishable in crime
 Professionals
such
as
lawyers,
doctors,
architects are treated differently in criminal
negilgence
Negligence
j
Reasonable Competence
He should not lag behind other ordinary
assiduous and intelligent members of his
profession in knowledge of new advances,
discoveries and developments in his field
j
Negligence
This is not the intention of law
Surgeon with shaky hands
Quivering physician
Negligence
j
General Exceptions in Law
Section 88
provides exemption not intended to cause
death, done by consent in good faith for
person’s benefit.
Negligence
j
General Exceptions in Law
Section 92
exemption for acts done in good faith for
the benefit of the person without his
consent though the acts caused harm to
the person and the person has not
consented to suffer such harm.
j
Negligence
General Exceptions in Law
Section 93
Saves from criminality certain
communications made in good faith
Negligence
j
Link between moral fault, blame
and justice
The social efficacy of blame and related
sanctions in particular cases of
deliberate wrong doings may be a matter
of dispute,
but their necessity in principle from a
moral point of view, has been accepted
BLAME CANNOT BE OVEREMPHASIZED
Link
Negligence
j
between moral
fault,
blame
and justice
 A violation is culpable
 Professional negligence – the interest
of the plaintiff and the interest of the
defendant
 Criminal Offence – morally unworthy
state of mind – recklessness and
deliberate wrong doing are so
Link
Negligence
j
between moral
fault,
blame
and justice
 A violation is culpable
 Professional negligence – the interest
of the plaintiff and the interest of the
defendant
 Criminal Offence – morally unworthy
state of mind – recklessness and
deliberate wrong doing are morally
unworthy
Link
Negligence
j
between moral
fault,
blame
and justice
 Blame is a powerful weapon
 Calling for punishment on account of
being gross or of a very high degree
requires for careful, morally sensitive
and scientifically informed analysis
Link
Negligence
j
between moral
fault,
blame
and justice
 Professional – Negligence – two counts
 Either he was not possessed of the
requisite skill which he professed to
have possessed
Or, he did not exercise, with
reasonable competence in the given
case, the skill which he did possess
Link
Negligence
j
between moral
fault,
blame
and justice
 The test for determining as laid down
in Bolam’s case holds good in its
applicability in India
 English tort law – negligence
 Bolam’s Test – “ If a doctor reaches
the standard of a responsible body of
medical opinion, he is not negligent
Negligence
j Opinion
The Final
A private complaint may not be
entertained unless the complainant has
produced prima facie evidence before
the court of rashness and negligence on
the part of the accused doctor.
Negligence
j Opinion
The Final
The investigating officer should, before
proceeding against the doctor accused
of rash and negligent act or omission,
obtain an independent and competent
medical
opinion
preferably
from
a
doctor in govt service qualified in that
branch – applying Bolam’s test
Negligence
j Opinion
The Final
A
doctor
accused
of
rashness
and
negligence, may not be arrested in
routine manner. Unless needed for
• furthering the investigation
• for collecting evidence
• or likely to make himself unavailable
j
Negligence
VICARIOUS LIABILITY – Liability for
act of another
PRODUCTS LIABILITY
j
Negligence
Parmanand Katara Case
The Code of Medical Ethics,1970,
reveals unfortunate state of affairs
where the decisions taken at the
highest level good intentioned and for
public good but unfortunately do not
reach the common man and it only
remains as a text book to read and
attractive to quote
j
Negligence
Parmanand Katara Case
Article 21 of the Indian Constitution
casts the obligation on the state to
preserve life
 A doctor at Govt hospital positioned
to meet this state obligation is,
therefore duty bound to extend medical
assistance for preserving life
j
Negligence
Parmanand Katara Case
EVERY DOCTOR WHETHER AT A GOVT
HOSPITAL OR OTHERWISE HAS THE
PROFESSIONAL OBLIGATION TO EXTEND
HIS SERVICES WITH DUE EXPERTISE FOR
PROTECTING LIFE
Negligence
j
Parmanand Katara Case
A physician is free to choose whom he
will serve. He should, however, respond
to any request for his assistance in any
emergency or whether temperate public
opinion expects the service
j
Negligence
Parmanand Katara Case
Medical profession is a very noble
profession. Doctor is looked upon by
common man as the only hope when a
person is hanging between life and
death but they avoid their duty to help
the person when he is facing death
whey they know that it is a medicolegal case
Negligence
j
Parmanand Katara Case
WE WOULD ALSO LIKE TO MENTION THAT WHENEVER OF
SUCH OCCASIONS A MAN OF THE MEDICAL PROFESSION
IS APPROACHED AND IF HE FINDS THAT WHATEVER
ASSISTANCE HE COULD GIVE IS NOT SUFFICIENT REALLY
TO SAVE LIFE OF THE PERSON BUT SOME BETTER
ASSISTANCE IS NECESSARY – IT IS ALSO THE DUTY OF
THE MAN IN THE MEDICAL PROFESSION SO APPROACHED
TO RENDER ALL THE HELP WHICH HE COULD AND ALSO
SEE THAT THE PERSON REACHES THE PROPER EXPERT AS
EARLY AS POSSIBLE
Negligence
j Mazdoor Samiti
Paschim Banga Khet
Case
 Art 21 – Right to life. Human life is
of paramount importance
 Obligation on state – lack of financial
resources on reason not to provide
 The court stated that denial of timely
medical
treatment
necessary
to
preserve in govt-owned hospitals is a
violation of this right
Wrong Drug
Confusion over sound alike drugs /
look-alike
Glynase
Zynase
Metalar
Metadac
Reglan
Reflin, Reflin
Allegra
Edegra
Glimer
Galamer
Folinic acid
Folic acid
Acicot
Aciloc
National Accreditation
Board for Hospitals &
Healthcare Providers
(NABH)
Standardization and its
Uniform implementation is
the panacea to all issues
of Medical Negligence
Medical Services have no
meaning if does not meet
the minimum quality
standards in the
respective areas
N A B H Accredited
Hospitals
 In India: 163
 In Karnataka: 19
 In Bangalore: 15 hospitals
N A B H
 NABH is a constituent board of Quality Council
of India
 It is set up by Government of India
 To establish & operate accreditation program
for Hospitals and Healthcare Providers
 To set benchmarks for progress of Healthcare
Organizations
Quality Aspects of
Healthcare
EXPECTATIONS
 Rendering
acceptable
quality
care
affordable prices to patients
 Timely access and care of patients
 Clear communication to the patients
 Best practices for fixing appointment
service delivery
 Reliable diagnostic and laboratory support
at
and
Quality Aspects of
Healthcare
 Reliable support services (Canteen, ambulance,
pharmacy, etc)
 Efficient in-patient services, with a goal towards
zero errors
 Safe and pleasant environment
 Technical competence of Staff
 Courtesy and attitude of Staff
NABH STANDARDS FOR
HOSPITALS
Second Edition
 10
- CHAPTERS
 63 - STANDARDS
 294- OBJECTIVE ELEMENTS
NABH STANDARDS
Chapters
1. Access, Assessment and Continuity of care
(AAC)
2. Care of Patients (COP)
3. Management of Medication (MOM)
4. Patient Rights and Education (PRE)
5. Hospital Infection Control ( HIC)
NABH STANDARDS
6. Continuous Quality Improvement (CQI)
7. Responsibility of Management (ROM)
8. Facility Management and Safety (FMS)
9. Human Resource Management (HRM)
10. Information Management System (IMS)
1. Access, Assessment
and Continuity of Care
 Matching
patient’s
requirements
organization's resources
with
 Initial assessment and periodic and regular
assessments of patients in the hospital
 Laboratory services
 Radiology services
 Transfer and discharge protocols
2. Care of Patients
 Uniform care
delivery
 Emergency services
 Ambulance services
 Blood and blood
products
 Intensive care and
HDU
 Vulnerable patients
 Pediatric patients







Surgical patients
Restraints
Pain management
Rehabilitative
services
Research
activities
Nutritional
therapy
End of life care
3. Management of
Medicine









Pharmacy services
Hospital formulary
Storage of medication
Prescription of medications
Dispensing of medication
Medication administration
Narcotic and psychotropic substances
Chemotherapeutic drugs
Medical gases
4. Patient Rights and
Education
 Protects patient and family rights
 Protecting
beliefs,
values
and
involvement in decision making
 Informed consents
 Right
of
information
and
about healthcare needs
 Information on expected costs
education
5. Hospital Infection
Control
 Infection control program
 Surveillance activities
 Actions taken to prevent or reduce the
risk of hospital associated
infection(HAI)
 Facilities and resources provision
 Control outbreaks of infection
 Biomedical waste management
6. Continuous Quality
Improvement
 Key indicators – Clinical structures,
processes and outcomes
 Key indicators – Managerial structures,
processes and outcomes
 Quality Assurance program
 System for audit of patient care
services
 Sentinel events analysis
7. Responsibility of
Management
 Responsibilities of management are defined
 Scope of services is documented
 Hospital managed in ethical manner
 Qualified and experienced individual
heads the organization
 Patient safety and risk management issues
addressed
8. Facility Management &
Safety
 Laws, byelaws, rules and regulations
 Facility for safety of patients, families staff
and visitors
 Equipment management
 Fire and non fire emergencies
 Smoking policy
 Disaster management policy
 Hazardous materials handling
9. Human Resource
Management
 HR planning
 Training & development
 Credentialing
 Regular appraisals (Skills & knowledge
assessment forms)
 Basic life support (BLS) education to all
staff
 Health needs addressed
 Personal records
 Disciplinary procedure
10. Information
Management System
 Management of information needs
 Medical records
 Confidentiality, integrity and security
 Retention of records
 Medical audits
BENEFICIARIES OF
ACCREDITATION
PATIENTS
Accreditation results in high quality
care and patient safety
Service delivered through credentialed
medical staff
Rights
of
patients
respected
and
protected
Patients satisfaction
evaluated
regularly
BENEFICIARIES OF
ACCREDITATION
HOSPITALS
Stimulates continuous improvement
Enables hospitals demonstrate their
commitment to quality care
Raises the community’s confidence in the
services provided by the hospital
BENEFICIARIES OF
ACCREDITATION - Hospitals
Provides opportunity to health
care units to benchmark with the
best
Enable better rates from
insurance companies (new
grade structure A,B, & C
announced)
Promotes Medical Tourism
BENEFICIARIES OF
ACCREDITATION
HOSPITAL STAFF
 Satisfaction as it provides
Continuous learning,
Good working environment,
Leadership and ownership of clinical processes
 Improves overall professional
improvement of clinicians and health care
staff
 Provides leadership for quality improvement in
medicine and nursing
OTHER BENEFITS…
 Helps in drastic reduction in a
variety of medical and surgical
errors.
 Reduction in injuries to staff, reduction
in injuries to patients.
 Ensures safe medication
administration and care
 Creates a safety culture throughout the
Hospital
Model Health InstitutionsClean and Hygienic interior
Model Health InstitutionsPatient friendly waiting room
Model Health
Institutions-Citizen Charter
Model Health
Institutions-Neonatal Corner
KAVERIPAKKAM PHCFRONT VIEW
PHC PALLIKONDA
PHC PUDUPADI
KAVERIPAKKAM PHC
Garden
Field issues
Declaration
of
Alma-Ata
International
conference on primary health care, Alma Ata,
USSR 1978
“Health for All by 2000”
Field issues
Quality of medical students

Attitude towards patients—humanity, concern

Attitude towards learning— not to get degree or
pass but to have proper knowledge

Wrong diagnosis because of lack of knowledge

Refusal
of
mandatory
laws
to
work
in
government hospitals after MBBS
 Unnecessary investigations show lack of knowledge
 Poor at spot diagnosis
Field issues
Poor facilities provided at government
hospitals

To doctors

Patients – transportation facilities

To hospitals- infrastructure, staffs, paramedical
staffs, group D staff

Not to be constructed at out skirts

Ambulance, communication to referral hospitals

No timely supply of essential drugs
Field issues
Reasons for not working at government
hospitals

Improper accommodation facilities

Repeated transfers

Interference of local politicians

Posting of master degree holders to rural areas

Only undergraduate doctors are necessary for
rural areas

Hindrance by local authorities

Security issues
Field issues
Medical colleges are factories producing
doctors who are incapable
 Unnecessary investigations show lack of knowledge
 Poor at spot diagnosis
 Quality of doctors from medical institutions has to be
improved in their practical exposure and knowledge
 They
need
to
establish
a
good
doctor
patient
relationship

Case sheets – incomplete documentation, discharge cards
incomplete information
Field issues
Government
 Negligence in budget at rural levels
 Generation to generation medical services
are deteriorating
Field issues
To improve

Good
education
system
for
doctors
paramedical staff and nurses

Primary care which is

Accessible

Affordable

Acceptable

Approachable

Fund raising

Central, from health tax, poor fund boxes
and
Field issues
Prevention is better than cure

Nutritional food

Clean water

Disposal of waste

Environmental studies

Health education
NUTRITIONAL DIVERSITY
Facts:
Three billion live on less than 2 $ per day,
1.5 billion on less than 1 $ per day and cannot
afford a diversified diet or industrially produced
supplements
Millions are chronically micronutrient
malnourished
Edible Vaccinces
Golden Potato, Diretto et al., PlosOne, 2007
What does the Future Hold?
“Although agricultural genetic
manipulations will inevitably be
regulated by governments, the
ease of suggesting and making
desired manipulations should
ensure that, by the middle of
this century, most of the plants
in any cultivated landscape will
carry genetic alternations guided
by genomic research”.
Roger Brent (2000) Genomic Biology. Cell 100:
169-183
“The public accepts biotechnology in medicine
because it sees a clear benefit: saving
lives.
But about all crop biotechnology can do for
now is make plants that are easier and
cheaper for farmers to grow. While that’s
great for farmers it’s hardly an appeal to
middle class consumers, particularly when
they are being cautioned by opponents that
the foods’ safety hasn’t been approved.”
- Robert Shapiro, president of Monsanto
Basic principle of law
of torts

A tort, in common law jurisdictions, is a civil wrong

Tort law deals with situations where a person's
behaviour has unfairly caused someone else to suffer
loss or harm
 A tort is not necessarily an illegal act but
causes harm
 The law allows anyone who is harmed to
recover their loss
Basic principle of law
of torts
 Tort law is different from criminal law, which
deals with situations where a person's actions
cause harm to society in general
 A claim in tort may be brought by anyone
who has suffered loss after suing a civil
law suit
The Need for
Consumer Law
Patient is a consumer now
Need has always been
there
The need has always been
there
The need has always been
there
CONSUMER PROTECTION
LAW
CONSUMER PROTECTION
LAW
Basic principles of law
of consumer
 The definition of Consumer right is 'the right to
have information about the quality,
potency,
quantity, purity, price and standard of goods
or services’, as it may be the case,
 But the consumer is to be protected against any
unfair practices of trade.
CONSUMER PROTECTION
LAW
An Act
“To provide for better protection of the
interests
of
consumers
and
for
that
purpose to make provision for establishment
of consumer councils & other authorities for
the settlement of consumer disputes and
for matters connected therewith”.
Consumer Disputes Redressal
Agencies
Financial Powers
District Forum
Up to Rs 20 lakh,
State Commission
Up to Rs. 1 Crore,
National commission
More than 1 Crore
Who is a Consumer
 A consumer is a buyer of goods or
hirer of services
 Buys goods for a consideration which
has been paid or promised or partly
paid and partly promised
 Hires or avails of any service for a
consideration which has been paid or
promised or partly paid and partly
promised
What is Service
 Service of any description which is
made available to potential users and
includes but not limited to the
provision of facilities like banking,
finance, insurance etc..
 Whether medical treatment is a
service?
Kishori Lal v. E.S.I
Corporation II (2007) CPJ
25 (SC)
• Appellant insured with the ESI Corporation
• Deduction made from his salary by the employer
and deposited with the corporation
• Appellant’s wife admitted in ESI dispensary at
Sonepat for treatment of diabetes
• Her condition deteriorated
• Later examined in a private hosp
• Wrongly diagnosed at ESI dispensary
• Complaint filed under CPA
Kishori Lal v. E.S.I
Corporation II (2007) CPJ
25 (SC)
 Supreme Court in revision petition held that
services rendered by medical practitioners of
hospitals / nursing homes run by ESI
Corporation
cannot be regarded as
service rendered free of charge
 Since Sections 39 and 42 of the ESI Act
contemplate contributions from both the
employer and the employee, which can be
deemed to be fee for the service.
PRECAUTIONS AGAINST
NEGLIGENCE
 Contact legal advisor
 Never tamper with patients records
 Always date clearly any addition to
notes
 Educate yourself further in the subject
PRECAUTIONS AGAINST
NEGLIGENCE
 Proper medical records provide evidence of
treatment given in the event of claim
 Medical records tampered with or missing may
turn a defensible case into an indefensible one
 Remember not to let self-doubt creep in,
continue to keep good relationship with patient,
give a follow up appointment, keep good records
And Finally….
 Explain all treatment
 Get consent
 Accurate notes of the
unusual
 Care with risky
patients
 Correct mistakes free
 Tell the patient about
it
 Avoid excessive force
 Keep contemporaneous
records of all
accidents and incidents
 Report untoward incidents
promptly
to
your
Organisation
 Do not act as an expert
unless you are! And can be
unbiased
 Keep up to date with
literature
and
new
developments
 Not
all
unsatisfactory
outcomes are negligence
 Seek prompt advice
The insurmountable
 Resources - infrastructure
 Human Resources
 Technology
 Quality standards
 DOCUMENTATION
 Organizational culture –work culture
 are you a part of the society
The ROADMAP
 commitment of oath
 Service as a motto
 phased implementation of technology
and its usage
 AN ERP SOLUTION
 Quality standards -0 tolerance
 DOCUMENTATION
The ROADMAP
 Improve quality of education
 UPGRADATION OF SKILLS
 Commitment to community
 KNOW WHAT YOU DO AND DO WHAT
YOU KNOW
Conclusion
We are not in happy situation and that is
of our making. Things can change
dramatically with attitudinal change and
giving in more effort and time. Proactive
leadership in the key. Strict
implementation of quality standards and
use of appropriate technology is critical.
High standard medical education and
upgrade of knowledge and skills and
leverage the country into the next level of
health care
WE ARE ON THE
VERGE OF THE
INDIAN HEALTH
CARE
REVOLUTION
Lets
Make
It
hAPPEN
THANKS FOR THE
RAPT ATTENTION
Will meet shortly
Ethics Committee bans
doctor for negligence
 Pankaj Rai Vs Fortis Hospital, Bangalore
 Negligence-
Pancreas
Transplant
without
permission.
Not obtained Informed Consent.
 Dr
Ramcharan
Thiagarajan,
a
transplant
surgeon, Erasure of name for one year on
charges of medical negligence, by Medical
Council of India (MCI)
Compensation for
wrong treatment
 Kishan
Rao’s
Vs
Nikhil
Super
Speciality
Hospital, Hyderabad
 Negligence- Treated for Typhoid instead of
malaria
Patient died
 Supreme court ordered that no expert opinion
is required and directed the hospital to pay
the compensation
Man gets Rs.1 lakh
for medical negligence
 Javeed Vs C.S.I. Rainy Hospital, Chennai
 Negligence- Operated on the wrong side
for a hernia
 Compensation
of
one
lakh
paid
‘unnecessary suffering and agony’.
the