MEDICOLEGAL ASPECTS OF ANAESTHESIA AND

DILEMMAS TO ANAESTHETIST

BYBY

DR.P.NARASIMHA REDDY M.D,D.A,DR.P.NARASIMHA REDDY M.D,D.A,

HOD, DEPT OF ANAESTHESIOLOGY,HOD, DEPT OF ANAESTHESIOLOGY,

KURNOOL MEDICAL COLLEGE,KURNOOL MEDICAL COLLEGE,

KURNOOL (A.P). KURNOOL (A.P).

1) INTRODUCTION1) INTRODUCTION

2) UNDERSTANDING OF MEDICOLEGAL 2) UNDERSTANDING OF MEDICOLEGAL

ASPECTS.ASPECTS.

3) MEDICOLEGAL DILEMMAS.3) MEDICOLEGAL DILEMMAS.

INTRODUCTION

””MAN CAN BUT ACHIEVE TRANSITORY MAN CAN BUT ACHIEVE TRANSITORY SLEEP WHILE LORD CAN PUT HIM TO SLEEP WHILE LORD CAN PUT HIM TO ETERNAL SLEEP” -Dr. Graham pearce.ETERNAL SLEEP” -Dr. Graham pearce.

-Anaesthesia improved quality of all surgical -Anaesthesia improved quality of all surgical procedures.procedures.

-Certain agents and techniques are source of -Certain agents and techniques are source of morbidity and mortality.morbidity and mortality.

-Any intervention does carry an element of risk.-Any intervention does carry an element of risk.

INTRODUCTION (contd)

1987 confidential enquiry into perioperative 1987 confidential enquiry into perioperative deaths.deaths.

Anaesthesia as sole cause of death 0.1%.Anaesthesia as sole cause of death 0.1%. Contributory factor 14% of cases.Contributory factor 14% of cases. Practice of anaesthesia has many interfaces with Practice of anaesthesia has many interfaces with

law.law. State has the responsibility to protect the citizens.State has the responsibility to protect the citizens. State has a role to regulate the behaviour of State has a role to regulate the behaviour of

physicians and hospitalsphysicians and hospitals

INTRODUCTION (contd)

New technologies always emerge and are applied New technologies always emerge and are applied in practice of medicine and may create new in practice of medicine and may create new interfaces between medicine and jurisprudence.interfaces between medicine and jurisprudence.

New technologies may change the practice of New technologies may change the practice of anaesthesia practice.anaesthesia practice.

Anaesthesia practice is neither insulated nor Anaesthesia practice is neither insulated nor immunized against medical jurisprudence.immunized against medical jurisprudence.

““Nothing is static everything is changing”.Nothing is static everything is changing”.

UNDERSTADING OF MEDICOLEGAL ASPECTS “ “FEAR OF UNKNOWN HAUNTS US”FEAR OF UNKNOWN HAUNTS US” BOLAM TEST:”A doctor is not negligent if he is BOLAM TEST:”A doctor is not negligent if he is

acting in accordance with a practice accepted as acting in accordance with a practice accepted as PROPER by responsible body of medical men PROPER by responsible body of medical men skilled in that art even though other doctors adapt skilled in that art even though other doctors adapt a different practice”.a different practice”.

The test is applied in diagnosis, to advice and to The test is applied in diagnosis, to advice and to treat the patient. treat the patient.

UNDERSTADING OF MEDICOLEGAL ASPECTS (contd) LORD SCARMAN restated that “a doctor is not LORD SCARMAN restated that “a doctor is not

negligent if he acts in accordane with the practice negligent if he acts in accordane with the practice accepted accepted at that timeat that time as as proper by a responsible proper by a responsible bodybody of medical opinion even though other of medical opinion even though other doctors adopt a different practice”.doctors adopt a different practice”.

Later it is amended, saying that if jury is not Later it is amended, saying that if jury is not satisfied with procedure done by defendant which satisfied with procedure done by defendant which is even backed by medical body can proved is even backed by medical body can proved negligent. negligent.

UNDERSTADING OF MEDICOLEGAL ASPECTS (contd) Fatalities associated with anaesthesia, surgery and Fatalities associated with anaesthesia, surgery and

diagnosis can be categorized as:diagnosis can be categorized as:

1)Those directly caused by disease or injury for which 1)Those directly caused by disease or injury for which anaesthesia was necessary.anaesthesia was necessary.

2)Death caused by a disease or co morbid conditions 2)Death caused by a disease or co morbid conditions other than the disease for which anaesthesia was given.other than the disease for which anaesthesia was given.

3)Surgical or diagnostic procedural mishap.3)Surgical or diagnostic procedural mishap. 4)Anaesthesia mishaps4)Anaesthesia mishaps a) over dosagea) over dosage b) technical failureb) technical failure c) equipment failurec) equipment failure d) negligenced) negligence

UNDERSTADING OF MEDICOLEGAL ASPECTS (contd) “ “ERROR IS HUMANERROR IS HUMAN” ” Human error: Human error: a) Emergency setupa) Emergency setup b) Lack of sleepb) Lack of sleep c) Lack of experience with technique and c) Lack of experience with technique and

equipmentequipment d)lack of skilled assistantd)lack of skilled assistant e) restricted access to the patient and e) restricted access to the patient and f) Inadequate vigilance.f) Inadequate vigilance.

UNDERSTADING OF MEDICOLEGAL ASPECTS (contd)COOPER, NEWBOVER AND KITZ described three COOPER, NEWBOVER AND KITZ described three

categories:categories:

1)1)TechnicalTechnical: deficiency of technical skills and : deficiency of technical skills and poor design of equipment poor design of equipment

2)2)JudgementalJudgemental: bad decision due to poor training : bad decision due to poor training and anxietyand anxiety

3) 3) Monitoring and vigilance failureMonitoring and vigilance failure- failure to - failure to recognize the problem and delayed response.recognize the problem and delayed response.

UNDERSTADING OF MEDICOLEGAL ASPECTS (contd)

What is a contract?What is a contract? In medical practice the duty of care is In medical practice the duty of care is

based upon the contract, real or implied based upon the contract, real or implied between the doctor and the patient.between the doctor and the patient.

Working to and working for:Working to and working for: The anaesthetists are called by the surgeons The anaesthetists are called by the surgeons

or nursing homes, the whole responsibility of or nursing homes, the whole responsibility of the patient lies on them.the patient lies on them.

When patient approaches the anaesthetist When patient approaches the anaesthetist the responsibility lies on the anaesthetist. the responsibility lies on the anaesthetist.

UNDERSTADING OF MEDICOLEGAL ASPECTS (contd)It is the duty of the anaesthetist to attend the patient, assess It is the duty of the anaesthetist to attend the patient, assess

him and optimise the patient with necessary investigations him and optimise the patient with necessary investigations and treatment.and treatment.

No guarantee should be given regarding awareness or No guarantee should be given regarding awareness or morbidity.morbidity.

Duty to provideDuty to provide: It is the duty of the government or hospital : It is the duty of the government or hospital management to provide adequate and trained hands. They management to provide adequate and trained hands. They must provide all necessary latest functioning equipment. must provide all necessary latest functioning equipment. Trainee should be regularly supervised by the seniors.Trainee should be regularly supervised by the seniors.

UNDERSTADING OF MEDICOLEGAL ASPECTS (contd)Anesthetist must attend the patient a day before Anesthetist must attend the patient a day before

surgery, do PAC and everything must be surgery, do PAC and everything must be documented.documented.

Duty to explainDuty to explain: Anaesthetist must explain clearly : Anaesthetist must explain clearly the procedure contemplated, type of anaesthesia the procedure contemplated, type of anaesthesia other modalities of treatment and complications of other modalities of treatment and complications of procedure.procedure.

Nothing should be decided against the patient will.Nothing should be decided against the patient will.

UNDERSTADING OF MEDICOLEGAL ASPECTS (contd)What is consentWhat is consent??

It is defined as “voluntary agreement, compliance It is defined as “voluntary agreement, compliance or permission for a specified act or purpose”.or permission for a specified act or purpose”. Indian contracts act section 13 states that “two Indian contracts act section 13 states that “two or more persons said to consent when they or more persons said to consent when they agree upon the same thing in the same agree upon the same thing in the same sense”sense” Consent must be intelligent and informed.Consent must be intelligent and informed. Without consent it amounts to assault and Without consent it amounts to assault and battery.battery.

CONSENT (contd)Consent may be either expressed or implied.Consent may be either expressed or implied.Expressed consent may be written or verbal.Expressed consent may be written or verbal.Implied consent is for routine small procedures .Implied consent is for routine small procedures .Written consent is a must for specialised Written consent is a must for specialised

procedures.procedures.Must be taken in the presence of third party.Must be taken in the presence of third party.Informed consent: the procedure is explainedInformed consent: the procedure is explained to the patient in his local language and consentto the patient in his local language and consentis taken.is taken.

CONSENT (contd)

Doctrine of informed consentDoctrine of informed consent::

1) All relevant information about ailment and treatment 1) All relevant information about ailment and treatment options outlined.options outlined.

2) Significant risks with the procedures explained.2) Significant risks with the procedures explained.

3) Must be told about all other options of treatment.3) Must be told about all other options of treatment.

4) Explained in local vernacular so that he can 4) Explained in local vernacular so that he can understand and consent.understand and consent.

What is the legality of consent?What is the legality of consent?

CONSENT (contd)Theraputic privilege:Theraputic privilege:Doctor can with hold some information in the best Doctor can with hold some information in the best

interest of the patient.interest of the patient.Extension doctrine:Extension doctrine:Sometimes doctor has to exceed the procedure than the Sometimes doctor has to exceed the procedure than the

consented because of practical problems and it is consented because of practical problems and it is allowed by court.allowed by court.

The consent given must be- voluntary and free. Consent The consent given must be- voluntary and free. Consent obtained by fear, force and fraud is invalid.obtained by fear, force and fraud is invalid.

Blank consent: Blank consent: For small procedures. For small procedures. Special informed consent for major Special informed consent for major procedures procedures

CONSENT (contd)

Consent may not be taken inConsent may not be taken in

1) Patient is in coma and needs emergency 1) Patient is in coma and needs emergency surgery.surgery.

2) Child patient for operation- parents not 2) Child patient for operation- parents not available.available.

3) When the case is referred by a court for 3) When the case is referred by a court for medicolegal purposes medicolegal purposes

CONSENT (contd)

Consent is taken fromConsent is taken from::1) Conscious, mentally sound adult.1) Conscious, mentally sound adult.2) Child above 12years.2) Child above 12years.3) The parent or guardian of child below 12 3) The parent or guardian of child below 12

years.years.4) Permission of loco parentis: e.g.:-4) Permission of loco parentis: e.g.:-

headmaster of a residential school.headmaster of a residential school.5) Jehovah’s witness.5) Jehovah’s witness.

The duty to provide safe Anaesthesia:The duty to provide safe Anaesthesia:1) Use Anaesthesia machine fully functional and well 1) Use Anaesthesia machine fully functional and well

maintained.maintained.2) Use monitors which warn unsafe gas mixtures, inadequate 2) Use monitors which warn unsafe gas mixtures, inadequate

saturation, inappropriate ventilation, cardiac arrhythmias, saturation, inappropriate ventilation, cardiac arrhythmias, heart rate, blood pressure and temperature. heart rate, blood pressure and temperature.

3) Check the equipment particularly those have been serviced 3) Check the equipment particularly those have been serviced recently.recently.

4) Continuing medical education training.4) Continuing medical education training.

5) Be physically and mentally active, ensure high 5) Be physically and mentally active, ensure high quality service.quality service.

6) Use techniques that are currently practiced and 6) Use techniques that are currently practiced and safe.safe.

7) Adequate written record of Anaesthetic procedure 7) Adequate written record of Anaesthetic procedure and monitoring data. “Black box” like evidence and monitoring data. “Black box” like evidence can be shown in times of need. A complaint of can be shown in times of need. A complaint of awareness can be now defended with latest awareness can be now defended with latest Bisindex monitoring.Bisindex monitoring.

UNDERSTADING OF MEDICOLEGAL ASPECTS

DUTY TO TELL WHEN THINGS GO DUTY TO TELL WHEN THINGS GO WRONG:WRONG:

Inform the patient’s attendants about the Inform the patient’s attendants about the complication.complication.

Slowly build up the scene.Slowly build up the scene.

Once they are mentally prepared, then we Once they are mentally prepared, then we can announce the bad result.can announce the bad result.

UNDERSTADING OF MEDICOLEGAL ASPECTS Failure to fulfill the duty of care:Failure to fulfill the duty of care:

If patient suffers damage during the procedure they may If patient suffers damage during the procedure they may claim negligence on the part of the anaesthetist.claim negligence on the part of the anaesthetist.

Legal action may be initiated against the doctors concerned.Legal action may be initiated against the doctors concerned. Plaintiff(patient) must prove negligence on the part of the Plaintiff(patient) must prove negligence on the part of the

doctor.doctor.

Res ipsa loquiturRes ipsa loquitur “The thing speaks for itself”. Here the “The thing speaks for itself”. Here the defendant physician must prove that the accident did not defendant physician must prove that the accident did not occur due to his negligence.occur due to his negligence.

MAL PRACTICE ISSUES

Consumer protection act 1986Consumer protection act 1986:: It has presidential consent on 24It has presidential consent on 24 th th DEC 1986.DEC 1986. Undergone two amendments 1) June 18Undergone two amendments 1) June 18thth 1993 and 1993 and

August 27August 27thth 1993. 1993. The purpose of act is to protect the consumer and The purpose of act is to protect the consumer and

safeguard his rights.safeguard his rights.The services rendered by doctors has been brought The services rendered by doctors has been brought

under CPA in 1995.under CPA in 1995. It has three tier system It has three tier system case must be filed within 2 years of accident.case must be filed within 2 years of accident.

MAL PRACTICE ISSUESPatient’s don’t come to hospital to file a suit.Patient’s don’t come to hospital to file a suit.If they are not happy or if there is any damage they may If they are not happy or if there is any damage they may

file a suit.file a suit.Professional plaintiff is rare.Professional plaintiff is rare.Who are litigious?Who are litigious?1) Currently involved in a law suit.1) Currently involved in a law suit.2) Has been a plaintiff in previous case.2) Has been a plaintiff in previous case.3) Had an adverse outcome from previous case.3) Had an adverse outcome from previous case.4) A hostile patient to physician or hospital.4) A hostile patient to physician or hospital.5) Patient who takes copious notes or records in 5) Patient who takes copious notes or records in

interview.interview.6) ‘Doctor shopping’ attitude.6) ‘Doctor shopping’ attitude.7) Degree of damage important.7) Degree of damage important.

RISK MANAGEMENT STRATEGIES1) Improve doctor-patient relationship1) Improve doctor-patient relationship

2) Adhere to standard care.2) Adhere to standard care.

3) Maintaining good records.3) Maintaining good records.

4) Respond properly when there is an 4) Respond properly when there is an accident.accident.

5) Recognize malpractice 5) Recognize malpractice prodromesprodromes..

6) Avoid vicarious responsibility.6) Avoid vicarious responsibility.

Notification of Law suit

After receiving a summon:- After receiving a summon:-

-Notify the insurer, he will appoint the lawyer, take -Notify the insurer, he will appoint the lawyer, take help of the lawyer to respond in specified time.help of the lawyer to respond in specified time.

-Don’t discuss about the patient with anyone.-Don’t discuss about the patient with anyone.

-We can see the medical records- Don’t alter it.-We can see the medical records- Don’t alter it.

-We can have a private counsel if there is a problem -We can have a private counsel if there is a problem with the insurer to protect our assets.with the insurer to protect our assets.

DISCOVERY

To ascertain the facts, there will be two sets of facts To ascertain the facts, there will be two sets of facts but only one set is true. It is duty of the jury to decide but only one set is true. It is duty of the jury to decide which one is true. Judges may also act as fact finders. which one is true. Judges may also act as fact finders. Medical record is the primary source of information.Medical record is the primary source of information.

Second source of fact is the testimony of those who Second source of fact is the testimony of those who witnessed the event. Don’t recall or imagine the witnessed the event. Don’t recall or imagine the things.things.

Third source is the usual practice pattern of the Third source is the usual practice pattern of the Anaesthetist. Routine actions during the Anaesthetic Anaesthetist. Routine actions during the Anaesthetic practice even if not recorded is taken as granted but practice even if not recorded is taken as granted but very credible.very credible.

Fourth source of the fact is expert witness testimony. Fourth source of the fact is expert witness testimony. Jurors may be laymen in medicine. They see the Jurors may be laymen in medicine. They see the medical records, doctors depositions.medical records, doctors depositions.

DEPOSITION OF TESTIMONY

It is taken by the plaintiff’s attorney from the defendant It is taken by the plaintiff’s attorney from the defendant doctor.doctor.

It should be in a convenient place, after good rest.It should be in a convenient place, after good rest.

Speak slowly, don’t loose temper, be composed and Speak slowly, don’t loose temper, be composed and neatly dressedneatly dressed

Speak yes or no to the questions.Speak yes or no to the questions.

EXPERT WITNESS:EXPERT WITNESS:

Most of the jury are not well informed about Most of the jury are not well informed about some topics in medicine. They need an expert opinion some topics in medicine. They need an expert opinion in solving the case. He must be qualified and well in solving the case. He must be qualified and well experienced in practice of Anaesthesia.experienced in practice of Anaesthesia.

ELEMENTS OF NEGLIGENCEDUTY OF CARE: every anaesthetist has a duty once DUTY OF CARE: every anaesthetist has a duty once

he accepts the work.he accepts the work. breach of duty may be due to acts of omission or acts breach of duty may be due to acts of omission or acts

of commission.of commission.Has got general duties and specific duties:Has got general duties and specific duties: Doctor is punishable under SEC 304-A IPC.Doctor is punishable under SEC 304-A IPC. 1) Physician failed to disclose inherent or 1) Physician failed to disclose inherent or

potential dangers involved.potential dangers involved. 2) Unrevealed risks materialized caused damage.2) Unrevealed risks materialized caused damage. 3) A reasonable patient would have deferred 3) A reasonable patient would have deferred

operation with risks involvedoperation with risks involved

ELEMENTS OF NEGLIGENCE

Standard of careStandard of care: : must adhere to standard practicemust adhere to standard practice need not be aware of latest developments.need not be aware of latest developments. must follow the protocols of the institution.must follow the protocols of the institution.Breach of dutyBreach of duty:: If there is an action of omission or commission If there is an action of omission or commission Which is acceptable by minority of anaesthetists Which is acceptable by minority of anaesthetists when doctor acts as a good Samaritan and helps when doctor acts as a good Samaritan and helps

an injured person he is immune to breach of duty. an injured person he is immune to breach of duty.

MAL PRACTICE ISSUES

CausationCausation: The link between breach and : The link between breach and injury is called proximate injury. Two listsinjury is called proximate injury. Two lists

1) 1) But forBut for: The injuries would not have : The injuries would not have occurred but for the Anaesthetic procedure.occurred but for the Anaesthetic procedure.

2)2) Substitute factor Substitute factor: The procedure need not : The procedure need not be only factor in causing injury.be only factor in causing injury.

MAL PRACTICE ISSUES

DamagesDamages Injuries sustained by the patient viewed generally as Injuries sustained by the patient viewed generally as

financial terms:financial terms:1) General damages: like pain, suffering, limitation 1) General damages: like pain, suffering, limitation

anxiety.anxiety.2) Special damages: like medical expenses, future 2) Special damages: like medical expenses, future

expenses, loss of wages and earning capacity and expenses, loss of wages and earning capacity and rehabilitation costs.rehabilitation costs.

Punitive damagesPunitive damages::In gross misconduct court may order exemplary or In gross misconduct court may order exemplary or

punitive damages. Insurance will not cover this.punitive damages. Insurance will not cover this.

MAL PRACTICE ISSUES

Closing a caseClosing a case::

1) Outside court settlement.1) Outside court settlement.

2) Court settlement if proved.2) Court settlement if proved.

Asset protection:Asset protection:

Insurance company escapes or partially pays Insurance company escapes or partially pays our assets are at stake. Select a good our assets are at stake. Select a good company with good past record.company with good past record.

MEDICOLEGAL DILEMMAS

Anaesthesia is a potentially dangerous Anaesthesia is a potentially dangerous discipline of medicine.discipline of medicine.

Bad outcomes do occur with senior or Bad outcomes do occur with senior or junior anaesthetist with or without junior anaesthetist with or without negligence.negligence.

The legal system is not always guided by The legal system is not always guided by truth but it is complicated by plaintiff’s truth but it is complicated by plaintiff’s mentality, lawyer’s business decisions.mentality, lawyer’s business decisions.

MEDICOLEGAL DILEMMAS

After a bad outcome the anaesthetist goes into a After a bad outcome the anaesthetist goes into a shell filled with anger, anxiety, frustration and shell filled with anger, anxiety, frustration and disappointment.disappointment.

This leads to depression.This leads to depression. People see him like a culprit and lawyers see him People see him like a culprit and lawyers see him

like a criminal.like a criminal. Most of the bad outcomes are not due to Most of the bad outcomes are not due to

negligence, but due to expected risk of anaesthesia negligence, but due to expected risk of anaesthesia and surgery.and surgery.

MEDICOLEGAL DILEMMAS

Many patients have known and unknown Many patients have known and unknown physical problems.physical problems.

Many patients have unrealistic expectations Many patients have unrealistic expectations regarding the outcome.regarding the outcome.

If the bad outcome is due to negligence it If the bad outcome is due to negligence it must be informed to the family and an must be informed to the family and an attempt must be made to settle the problem attempt must be made to settle the problem as early as possible.as early as possible.

MEDICOLEGAL DILEMMAS

The immediate response to bad outcomeThe immediate response to bad outcome: : If the critical event is for a short period and If the critical event is for a short period and

normalcy restored within few minutes surgery can normalcy restored within few minutes surgery can be allowed to take place.be allowed to take place.

Never rush to attendants to tell what happened Never rush to attendants to tell what happened without knowing the cause and don’t tell the without knowing the cause and don’t tell the possibilities.possibilities.

Surgeon and anaesthetist must discuss about the Surgeon and anaesthetist must discuss about the cause and possible outcome and then inform the cause and possible outcome and then inform the family members.family members.

MEDICOLEGAL DILEMMAS

if the critical event is serious and resuscitation if the critical event is serious and resuscitation took more than few minutes and the response is took more than few minutes and the response is slow the surgical team should consult the family slow the surgical team should consult the family members.members.

If surgery is not emergency postpone the case.If surgery is not emergency postpone the case.

If surgery is emergency it must be discussed in If surgery is emergency it must be discussed in detail with the family members and proceed.detail with the family members and proceed.

WHAT to????? What not to?????WHAT to????? What not to?????

HOW to reveal?? What about my future????HOW to reveal?? What about my future????

WHERE to go???? WHOM to talk????WHERE to go???? WHOM to talk????

MEDICOLEGAL DILEMMASRecord keeping:Record keeping: Enter correct timings Enter correct timings The surgical team must consult each other and record The surgical team must consult each other and record

the events.the events. If there is any difference of opinion if must be solved If there is any difference of opinion if must be solved

then and there but not in the court after few years.then and there but not in the court after few years. Nothing wrong in correcting an error Nothing wrong in correcting an error The correct time, date and reasons for correction must The correct time, date and reasons for correction must

be mentioned.be mentioned. The chart should not be altered.The chart should not be altered. Hospital authorities must be notified about an error in Hospital authorities must be notified about an error in

the chart.the chart. There should not be any “CHART WAR”.There should not be any “CHART WAR”.

RISK MANAGEMENT

The surgical team must contact the family The surgical team must contact the family members and explain what happened and members and explain what happened and what will be the outcome.what will be the outcome.

The family members should not be given a The family members should not be given a scope regarding if’s and but’s.scope regarding if’s and but’s.

If reason is not known it can be told.If reason is not known it can be told.

RISK MANAGEMENT

Contact with family members.Contact with family members.

1)Maintain good contact with family 1)Maintain good contact with family members.members.

2)Sudden bad news may generate anger in the 2)Sudden bad news may generate anger in the family members. Allow the anger to be family members. Allow the anger to be vented out. vented out.

3) Don’t involve or accuse other physicians.3) Don’t involve or accuse other physicians.

RISK MANAGEMENTCare of the patient after a bad outcomeCare of the patient after a bad outcome::1)1) Take care of the patient continuously Take care of the patient continuously 2)2) Never hand over the patient to others and leave the Never hand over the patient to others and leave the

scene.scene.3)3) Involve consultants, take their opinion regarding Involve consultants, take their opinion regarding

management.management.4)4) Do necessary investigations to clinch the diagnosis.Do necessary investigations to clinch the diagnosis.5)5) Shift the patient to a higher center if there is a Shift the patient to a higher center if there is a

necessity and follow the patient.necessity and follow the patient.6)6) Contact the family members at regular intervals and Contact the family members at regular intervals and

tell the progress of the patient.tell the progress of the patient. Try to gain the sympathy of the pt’s attendents.Try to gain the sympathy of the pt’s attendents.

RISK MANAGEMENT

The bad outcome is due to unknown cause or The bad outcome is due to unknown cause or no negligence.no negligence.

1)Insurance company must be notified.1)Insurance company must be notified.2) Expert opinion must be sought in the court 2) Expert opinion must be sought in the court

to clarify the causation.to clarify the causation.3) The 3) The plaintiff must prove the negligence on plaintiff must prove the negligence on

the part of the doctor.the part of the doctor. (It is not so easy).(It is not so easy).

RISK MANAGEMENT

PREPERATION FOR DEPOSITION;-PREPERATION FOR DEPOSITION;-

The plaintiff’s attorney will take the deposition .The plaintiff’s attorney will take the deposition .

The place must be a convenient one.The place must be a convenient one.

The physician must be composed. The physician must be composed.

Should not loose temper.Should not loose temper.

Answer to the questions by yes or no.Answer to the questions by yes or no.

No explanations.No explanations.

RISK MANAGEMENT

The deposition must address four major The deposition must address four major issues.issues.

1)The anaesthetist must know the events that 1)The anaesthetist must know the events that led to the bad outcome. led to the bad outcome.

2) He must have concept of what happened 2) He must have concept of what happened and it must be supported by literature.and it must be supported by literature.

3) Never try to flatter the plaintiff’s lawyer.3) Never try to flatter the plaintiff’s lawyer.4) Answer briefly and correctly.4) Answer briefly and correctly.

RISK MANAGEMENT

Never loose the heart . Hope for the best.Never loose the heart . Hope for the best.Take the opinion of the seniors regarding the Take the opinion of the seniors regarding the

case and the legal problems.case and the legal problems.Go through the literature to have support with Go through the literature to have support with

your views.your views.Have a separate lawyer if you are not happy Have a separate lawyer if you are not happy

with the lawyer appointed by insurance with the lawyer appointed by insurance company.company.

RISK MANAGEMENT

Support by the associations and colleagues:Support by the associations and colleagues:1)1) It is the duty of the association to come forward It is the duty of the association to come forward

and help his colleague morally, physically and and help his colleague morally, physically and financially.financially.

2)2) One should not speak bad about the incident and One should not speak bad about the incident and the doctor in the general public.the doctor in the general public.

3)3) Try to have a corpus fund to help the defendant Try to have a corpus fund to help the defendant doctor from medico legal suit’s and maintenance doctor from medico legal suit’s and maintenance of his family during crisis.of his family during crisis.

RISK MANAGEMENT

Medical indemnity:Medical indemnity:1)1) Select a good insurance company with a Select a good insurance company with a

good background.good background.2)2) Never entrust the work to an agent to Never entrust the work to an agent to

select the companyselect the company3)3) Never try to be Never try to be cost effectivecost effective..4)4) Read the contents of our agreement with Read the contents of our agreement with

the company thoroughly.the company thoroughly.

RISK MANAGEMENTStrategies to reduce bad outcomes:Strategies to reduce bad outcomes:1) 1) CMESCMES:: Have regular CMES, Have regular CMES, Share the knowledge Share the knowledge Frame guide lines and protocols for various Frame guide lines and protocols for various

procedures.procedures.2)2)Believe your monitorsBelieve your monitors:: Don’t find fault with the monitorsDon’t find fault with the monitors Try to find something wrong with the patient.Try to find something wrong with the patient. USE multiple monitors for cross checkingUSE multiple monitors for cross checking3) 3) Lab valuesLab values and clinical condition must correlate and clinical condition must correlate

RISK MANAGEMENT

ISA & ASA guidelinesISA & ASA guidelines::

The associations will be providing the The associations will be providing the members materials which contains members materials which contains standards, guide lines and malpractice standards, guide lines and malpractice claims. Anaesthesiologist must be thorough claims. Anaesthesiologist must be thorough with this information and follow.with this information and follow.

RISK MANAGEMENT

Policies and proceduresPolicies and procedures::

The policies formed to cover all the problems.The policies formed to cover all the problems.

They must be practicable and practicable. If They must be practicable and practicable. If not violation is proved by the lawyers.not violation is proved by the lawyers.

The policies must be reviewed regularly and The policies must be reviewed regularly and amended if necessary.amended if necessary.

RISK MANAGEMENT

Dealing with Dealing with angry patientangry patient and family and family members: members:

Most of the patients are unhappy and angry Most of the patients are unhappy and angry over the medical care.over the medical care.

We don’t have much time to spend with them We don’t have much time to spend with them because of emergency situation. because of emergency situation.

Don’t ignore them. Try to hear their problems Don’t ignore them. Try to hear their problems and assure them the possible solutions.and assure them the possible solutions.

RISK MANAGEMENT

RECORD KEEPINGRECORD KEEPING::Document all the happenings correctly with date and Document all the happenings correctly with date and

time.time.The team should discuss and fill the charts.The team should discuss and fill the charts.Charts should not be alteredCharts should not be alteredA liaison officer to deal with t he angry patients A liaison officer to deal with t he angry patients

attendants and to pacify them having a regular attendants and to pacify them having a regular contact with them.contact with them.

Anaesthesiologist must establish an algorithm to deal Anaesthesiologist must establish an algorithm to deal with the bad incidents.with the bad incidents.

CONCLUSIONS1)1) Assess the patient, optimise the patient and assure Assess the patient, optimise the patient and assure

the patient before taking up for surgery.the patient before taking up for surgery.

2)2) Take valid and informed consent Take valid and informed consent

3)3) Keep the things which are necessary during and Keep the things which are necessary during and after the operation.after the operation.

4)4) Check the equipment and monitors.Check the equipment and monitors.

5)5) Label all the drugsLabel all the drugs

6)6) Supervise the juniorsSupervise the juniors

7)7) Avoid critical incidentsAvoid critical incidents

CONCLUSIONS

8) If there is bad outcome contact the family 8) If there is bad outcome contact the family members and explainmembers and explain

9) Take opinion of consultants9) Take opinion of consultants

10) Do all the necessary investigations.10) Do all the necessary investigations.

11) Don’t leave the patient unattended11) Don’t leave the patient unattended

12) Take to a higher center if necessary12) Take to a higher center if necessary

13) Have a valid medical insurance coverage.13) Have a valid medical insurance coverage.

14) Try to avoid 14) Try to avoid physical assaultsphysical assaults by the angry by the angry patients attendants. patients attendants.