To err is human. However, there are certain ways of preventing errors to avoid medical mishaps, violence in the hospital and legal proceedings. This article elaborates on the ways medical negligence can be prevented and the importance of safe practice.

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The 21st century has seen many scientific and technological breakthroughs in the practice of medicine. As medicine became dependant on gadgets and instruments, the human touch gradually disappeared. Machines have slowly replaced human beings. But, it is rightly said, “The man behind the machine is more important."

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What is safe practice?

There can be errors both in the machine as well as the acts of an individual. So, it is always better to be safe than to be sorry. Safe practice means practising medicine keeping patients as well as ourselves safe from errors. It is different from ‘defensive practice’.

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Where can errors occur?

Errors in practice are common and can occur during history, examination, investigations, treatment etc. Errors of judgment, unexpected outcomes, known complications are not negligence on part of doctors/hospitals but we must be careful in reducing the medical errors. We have to strive for an error-proof system.

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Rights of patients

• To get proper medical attention and care
• Compassionate, human behaviour from the hospital staff
• Proper information and explanation for the disease
• Proper guidance regarding follow-up
• Preventive information against various diseases
• Explanation for referral
• Attention and hearing if the patient has complaints
• To refuse treatment or trial

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The scope of practice

Our scope or speciality of practice shall be as per our recognised qualifications, skill and experience. According to the Medical Council of India (Chapter 1.1.3), a physician having qualifications recognised and registered with the medical council shall only practice modern medicine.

According to the Supreme Court (SC) (Poonam Varma v. Ashwin Patel AIR (96) SC 2111) and many other case laws, if you are practising a system other than your qualification or registration, you are a quack.

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History and examination

Wrong history and improper examination can result in errors in diagnosis and treatment.

1. History of allergy should be recorded in each and every patient in order to avoid subsequent allegations of drug allergy/reactions.
2. Ask the history of the last menstrual period (LMP) in patients of childbearing age.
3. It is always better to have a list of common differential diagnoses rather than a single clinical diagnosis.
4. If examined in a hurry, ask to come for review.
5. Be a patient listener and show genuine concern.

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Investigations

Advice necessary investigations and avoid unnecessary investigations. Extra or costly investigations can have the allegation of extraction of money or collusion with the laboratory. If we don’t advise some investigation there can be allegations of not suspecting that diagnosis.

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Treatment

1. You have to be very careful while treating any patient because the maximum allegations are due to deficiency or error in treatment. There can be 'Cleavage of Opinion' as far as treatment is concerned (SC in Malay Kr Ganguli v. Dr Sukumar Mukherjee 2009 All SCR 2039).
2. You can follow any standard or accepted protocol (Bolam Principle) depending upon availability, circumstances and the consent of the patient/relatives. A valid, informed consent shall be taken (Samira Kohli v. Dr Manchanda I (08) CPJ 56 SC). Please don’t exceed the consent.
3. A second opinion from an equally competent or qualified practitioner may be helpful in complicated cases. If the case is beyond one's scope or qualification, refer to a higher centre. In critical cases follow a multi-speciality approach. Remember, individually we perform, collectively we excel.
4. Prescriptions should be written in capital letters (if handwriting is not legible), preferably generic drugs (Chapter 1.5 MCI Guidelines). Printed prescription shall be preferred. Avoid writing abbreviations of drugs that are not widely or well recognised. Avoid 'shot-gun therapy' or 'poly-pharmacy'.
5. The medicines shall be prescribed as per the requirements (Not over or under treatment), history of allergy, age-specific drugs etc. Write evidence-based medicines with proper justifications and precautions. Though most of the expiry dates drugs/vaccines don’t cause any harm to the patient but be careful and vigilant and follow the principle of first in-first out'.
6. We should be very careful with the drugs having narrow safety margins. If we want to write half (write as half, ½ or 0.5 and not as 0.5 ml or mg). A zero shall precede the decimal point. A drug that needs dilution shall be properly diluted or given in recommended IV drip.
7. Medication errors should be avoided in 'look-alike' or 'sound-alike' drugs. Many formulations, preparations or combinations may be available in markets with similar or resembling names; hence we must confirm the drug and dose before giving to the patient.
8. We should strive to minimise errors, risks or hazards. We are in the era of 'less is more' i.e. unnecessary investigations or treatment shall be avoided.

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Prevention of negligence

The allegations of negligence are very common in the present era. Our acts of commissions or omissions can result in damages to the patient or relatives. Hence, maintain proper documents and records.

The patients or the relatives have to prove the negligence by giving references or expert’s opinion. Record the contributory negligence (investigations not done, irregular treatment, follow-up etc) on part of patients/ relatives. Take due care to avoid incidences of 'Res Ipsa Loquitur'.

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The advantages of group practice

Group practice shall be preferred in the present circumstances. The various advantages include:

1. We get more time for family, social & other liabilities.
2. We can delegate liabilities to equally competent colleagues.
3. A Second opinion is easily available.
4. Different subspecialties can practice under one roof.
5. So the need for referral decreases.
6. There is an overall decrease in stress and strain.
7. Knowledge can be updated regularly.

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When to inform the police?

The police should be informed where we suspect any foul play, medico-legal cases or if there is a possibility of aggression or violence. We should be more careful while treating patients or relatives of 'Five Ps', that is:

• Press
• Politician
• Police
• Pleaders
• Professors

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Prevention of violence in the hospital

The incidences of violence have increased tremendously. We have to be very alert, suspicious and careful in preventing such mishaps.

1. Install CCTV cameras at recommended places especially to record time of arrival and time of attending the patient.
2. Restrict the entry of relatives or unauthorised persons.
3. Ask for photo-identity of the visitors or relatives.
4. Install alarm bells and warning systems in the hospital.
5. All establishments should develop an SOP for violence (Code Violet). We can have a 'no treatment list of offenders' circulated amongst our colleagues.
6. Inform the senior colleagues, med-legal organisations and police if there are some mishaps, misunderstandings or aggressive individuals. Have a crisis management committee.

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Indemnity or protection schemes

Financial safety in practice can be achieved with personal professional indemnity or hospital error and omission policies. The amount shall be based on our speciality, place and scope of practice etc. The policy should be taken in consultation with your colleagues, friends, previous experiences and the reliability of the company.

The practice of medicine has evolved from arts to science and finally to commerce. Ethics and economics may be adversaries but there is a need to have a balance between these two. We should follow the highest standard of professional conduct and do 'no harm' to the patients.

The doctor-patient relationship is deteriorating continuously and judicial activism and interventions are increasing. Policymakers have badly failed in improving the standard and safe medical practice.

We have to follow the rules and the laws of the land not only in words but also in spirit. Hence, our responsibility has increased. There is a need for lots of soul searching and self-introspection for legally and ethically error-free safe practice.

Disclaimer- The views and opinions expressed in this article are those of the author's and do not necessarily reflect the official policy or position of M3 India.

The author is the Founder President of the Indian Med-legal & Ethics Association.