Medical malpractice, which is defined as “patients’ harm resulting from healthcare professionals’ improper and unethical attitude or insufficient and sloppy practice”, is strictly limited to healthcare professionals’ errors in practice. However, it should include system error analysis. In this article, a missed case of system error resulted in death is presented to remind the concept to Forensic Medicine experts and review the literature.
A 20-year-old male who underwent renal transplantation from a live donor, underwent graft nephrectomy due to acute accelerated rejection. The patient with cardiac overload findings in the postoperative period, collapsed while the patient was being sent to a special center for urgent dialysis due to lack of functional dialysis unit. In the transfer ambulance, there was no oxygen source and the patient was unable to actively ventilate. The patient died while under intensive care. In our evaluation, system error has been detected and the administration was held responsible.
The experts who are asked about the medical malpractice have to take the basic concept of "medical error" as a basis for considering the mistakes of medical applications not only from the point of view of health professionals.
JCAHO. Sentinel Event Statistics 2006 [cited 2016 14.07]. Available from: www.jointcommission.org/Library/TM_Physicians/Tmp_11_06.Htm.
Bernstein M, Hebert PC, Etchells E. Patient safety in neurosurgery: detection of errors, prevention of errors, and disclosure of errors. Neurosurgery Quarterly. 2003;13(2):125-37.
Hakim RM, Lazarus JM. Initiation of dialysis. Journal of the American Society of Nephrology. 1995;6(5):1319-28.
Clark JE, Soricelli RR. INDICATIONS FOR DIALYSIS. The Medical clinics of North America. 1965;49:1213-39.
Greenberg A, editor Hyperkalemia: treatment options. Seminars in Nephrology; 1998.
SA M. The individual, the system, and medical error. 2003.
Rothschild JM, Landrigan CP, Cronin JW, Kaushal R, Lockley SW, Burdick E, et al. The Critical Care Safety Study: The incidence and nature of adverse events and serious medical errors in intensive care. Critical care medicine. 2005;33(8):1694-700.
Chiozza ML, Ponzetti C. FMEA: a model for reducing medical errors. Clinica Chimica Acta. 2009;404(1):75-8.
Bhasale AL, Miller GC, Reid SE, Britt HC. Analysing potential harm in Australian general practice: an incident-monitoring study. Medical Journal of Australia. 1998;169(2):73-6.
McDonald CJ, Weiner M, Hui SL. Deaths due to medical errors are exaggerated in Institute of Medicine report. Jama. 2000;284(1):93-5.
Dovey S, Meyers D, Phillips R, Green L, Fryer G, Galliher J, et al. A preliminary taxonomy of medical errors in family practice. Quality and safety in health care. 2002;11(3):233-8.
Kachalia A, Gandhi TK, Puopolo AL, Yoon C, Thomas EJ, Griffey R, et al. Missed and delayed diagnoses in the emergency department: a study of closed malpractice claims from 4 liability insurers. Annals of emergency medicine. 2007;49(2):196-205.
Hayward RA, Hofer TP. Estimating hospital deaths due to medical errors: preventability is in the eye of the reviewer. Jama. 2001;286(4):415-20.
Landrigan CP, Rothschild JM, Cronin JW, Kaushal R, Burdick E, Katz JT, et al. Effect of reducing interns' work hours on serious medical errors in intensive care units. New England Journal of Medicine. 2004;351(18):1838-48.
Blendon RJ, DesRoches CM, Brodie M, Benson JM, Rosen AB, Schneider E, et al. Views of practicing physicians and the public on medical errors. New England Journal of Medicine. 2002;347(24):1933-40.
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