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Islamov Shavkat Erjigitivich, senior lecturer, Department of Forensic Medicine and Pathological Anatomy, DSc., in Medicine, Samarkand Medical Institute, Samarkand, Uzbekistan E-mail: shavkat-smbe@rаmbler.ru
SUBJECTIVITY IN DEFECTS IN RENDERING MEDICAL AID
Abstract: Thus, a number of causes contribute to defects occurrence in various cases. Among defects causes subjective and organizational present the majority of cases. Among subjective causes the following facts prevail: incomplete examination of patients, inadequate qualification of medical personnel, careless treatment of patients. These defects were mainly observed in medical practice of obstetricians-gynecologist, surgeons, podiatrists, internists, traumatologists, neurosurgeons, paramedical personnel. With this subjective causes most often resulted in diagnostic and treatment defects, mistakes in administration and carrying out medical procedures (including irrational management of deliveries), defects in surgical treatment and organizational defects.
Keywords: Commission forensic medical examination, defects in the provision of medical care, subjective causes of occurrence, places of assumption.
gions Bureau and Chief Bureau of Forensic Medicine Expert Examination of Uzbekistan Public Health Ministry during the period from 1999 to 2008. Of 2.369 FMCEE concerning medical personnel, DMA were revealed in 4 9.4% (1171) of cases. Above-mentioned conclusions were thoroughly analyzed and appeared to be the material for study. In connection with above-mentioned conclusions the reports of 620 conclusions and 147 acts of Forensic Medicine Examination of corpses and alive persons, the other kinds of Forensic Medicine documents, the results of histological, chemical investigations'ets. were studied. In order to study the defects in rendering medical aid completely, taking into consideration peculiarities of medical practice, we developed modification of DMA classification, offered by Yu. I. Sosedko [7] in her work. Statistical processing of the received material, expressed in figures were carried out using the packet of statistical analyses of electronic tables Excel 2003 Microsoft office calculating average mistakes for mean arithmetic (M ± m). Difference were considered to be reliable if 0.01 < P < 0.05.
Results. Above-mentioned causes of DMA occurrence were conditionally generalized into 4 groups: exclusively subjective causes 1336(65.26%), organizational causes - 496(24.23%), objective causes - 156(7.62%), others - 59(2.88%). The revealed causes of DMA occurrence show that their number in 2000 decreased to 8,7% in comparison with the previous year, then increased gradually to 12.0% in 2003, then decreased to 10.9% in 2005 and to 6,6% in 2008.In percent correlation sharp prevalence of subjective causes in comparison with the other groups of causes is noticed. Among subj ective causes the majority are presented by: insufficient qualification of medical personnel (25.6%) and inadequate examination of the patients (24.8%). Analyses
Introduction. In countries with functioning Health Protection system the main attention is paid to the medical aid (MA) quality. At present the so-called Evidence-Based Medicine (EBM) appeared to be widely spread all over the world. EBM principles may be employed in evaluation ofMA quality [1; 6; 11; 14; 17].
The quality control means methodic questions of development of quality criteria and standards and carrying out comparative analysis on their basis; and to provide quality means to achieve the necessary level of medical care and its improvement [5; 7; 12]. The following classification of unfavourable outcomes in connection with carrying out medical measures taking into consideration the cause of their origin is offered:
1. The character and severity of the disease itself or trauma;
2. Iatrogenic diseases; 3. Accidents; 4. Defects in rendering medical aid (prophylactic, medical-prophylactic, medical rehabilitating measures) (DMA); 5. Medical mistake; 6. Medical delict [2; 3; 4; 8; 13; 16]. Deep study of medical aid organization in a number regions showed that the main blunders in early diagnostics and treatment of the revealed patients were made at prehospital stage (PHS). The patients were not examined thoroughly and did not receive an adequate treatment in the period of undoubted curability in almost half of cases and in the future they will present the contingent of patient with chronic, often incurable diseases, filling in-patient departments [9; 10; 15]. Thus a number of causes contribute to the development of DMA. Many authors consider that the majority of DMA appears due to be objective causes and their comprehensive study is actual at present and that is the aim of this paper.
Materials and research methods. Conclusions of Forensic Medicine Commission of Expert Examination (FMCEE), carried out for professional infringements of the law in all re-
Section 2. Medical science
of DMA development in speciality aspect showed that they were mainly noticed in medical practice of obstetricians-gynecologists (25.0%), surgeons (16.8%), podiatrists (8.0%) and other(P < 0.05).
Investigation of causes of DMA occurrence among different specialities showed the following: careless treatment of patients was in the main presented in practical activity of the emergency care units physicians (EC) (35.3%), paramedical personnel(30.6%), podiatrists (23.3%), internists (17.0%), and other.
Example 1. FMEEC Conclusion N59. T.T.- 50years old fell down and received bodily injuries on his working place in May. He was twice treated in CRH for 8-12 days with diagnosis''Acute pyelonephritis". In 2 years he was treated for 10 days in CRH with diagnosis "Chronic lumbar-sacral radiculitis with left side monopareses". Only in a year the diagnosis "Compressive fracture of X thoracic vertebra body and tumor of the spinal cord" was revealed in clinical hospital. In spite of two performed operations the patient died. In timely complete examination and treatment of the patient it was possible to save his life.
Insufficient qualification of medical personnel presented the majority of defects in medical practice of paramedical personnel(61.2%), reanimatologists (37.2%), traumatologists (34.6%), neurologists (27.0 and other. Inadequate examination prevailed in neurologists (54,1%), neurosurgeons (33.7%), traumatologists (28.1%), reanimatologists (21.5%), and other. Inter communication of DMA character and causes of their development show that they appeared due to subjective causes (65.26%), organizational (24.23%) and objective ones (7.62%). So development of subjective causes of diagnostic defects was often due to careless treatment of patients without correct diagnosis of the main disease (trauma) (13.5%) and its complications (21.1%) and also significant combining disease (4.6%); defects of treatment - mistakes in administration and performing medical procedures (11.2%), inadequate taking of medicines (5.6%), and other (P < 0.05). Insufficient qualification of paramedical personnel resulted in diagnostic defects - wrong diagnosis of the main disease (trauma) (14.9%) and its complication (23.1%), significant combining disease (5.2%); defects of treatment - mistakes in carrying out medical procedures (14.3%), defects of surgical treatment (9.4%), and other (P < 0.05). Inadequate examination results in diagnostic defects - incorrect diagnosis of the basic treatment(trauma) (16.5%) and its complications (24.8%), significant combining disease (7.7%); treatment defects result in mistakes in administration and performing medical procedures (including irrational management of deliveries) (8.5%), defects of surgical treatment (6.7%), and other (P<0,05). So in some specialities (obstetricians-gynecologists, surgeons) an increase of the studied signs is
noted. In the aspect of specialities it was marked as following: obstetricians-gynecologists show careless treatment of patients with different forms of clinical gestosis, postdelivery bleeding, postdelivery sepsis, premature placental separation, early rupture of amniotic fluid sac, unwillingness to hospitalize pregnant women with beginning deliveries, inadequate care for women in labor with pathological pregnancy, late follow up of pregnant women.
Inadequate qualification of medical personnel is one of the most often DMA. This sign as a cause of DMA occurrence was noted in medical practice of obstetricians-gynecologists 110(21.0%), surgeons 86(16.4%), reanimatologists 45(8.6%), traumatologists 53(10.1%), paramedical personnel - 30(5.7%), and other (P < 0.05). Surgeons show conceit in examination and treatment of patients, unqualified diagnostic investigations, unqualified preparation of patient to the operations, absence of consultative assistance, incorrect evaluation of examination results, iatrogenic injuries during operative interferences, underestimation of the patient's severe condition when he needs hospitalization and after operative interference. Reanimatologists-anesthesiologists have insufficient qualification in carrying out diagnostic investigations and medical interferences, in administration of medica-mental treatment for diagnosis of the brain edema, pulmonary edema, steady pneumonia; long "waiting" tactics, underestimation of the patient's severe condition, iatrogenic injuries in performing medical interferences, iatrogenic pathology in carrying out medicament therapy.
Example 2. FMEEC N6. T.A. 21 years old got bodily injuries and was hospitalized to medical sanitary unit. The diagnosis was: "Hypertonic crisis. Hypertonic disease of the III degree. Edema of the lungs and brain. Ischemic insult. Damage of cerebral circulation, right side hemipareses". In spite of performed medical measures there was a lethal outcome on the 5th day. The cause of the death was bleeding into the substance and ventricles of the brain, traumatic shock, fracture of nasal bones, VI, VII, VIII ribs on the left side and XI on the right one, the process of the 11 cervical vertebra, left radial and right tibial bones. These damages were not timely diagnosed due to insufficient qualification of the physician.
Incomplete investigation is most often the cause of subjective character in rendering medical aid. The received data show that such cause in DMA occurrence was observed in medical practice of obstetricians-gynecologists -116(22.8%), surgeons - 91(17.9%), grammatologists - 43(8.5%), internists - 41(8.1%), neurosurgeons and podiatrists in 34(6.7%), and other (P < 0.05). Reanimatologists anesthesiologists show incomplete examination in diagnosis of closed injuries of thoracic, abdominal cavities, cardiovascular and respiratory pathology during preparation and performing operations, in carrying out medical procedures, incomplete examination in
suspicion to alcohol intoxication, absence or incomplete use of consultative help, incomplete study of pathological course and also in diagnosis of complications of the main and combining pathology. The highest indexes show obstetricians-gynecologists and surgeons.
Conclusions. Thus, a number of causes contribute to DMA occurence in various cases. Among DMA causes subjective and organizational present the majority of cases. Among subjective causes the following facts prevail: incomplete ex-
amination of patients, inadequate qualification of medical personnel, careless treatment of patients. These defects were mainly observed in medical practice of obstetricians-gynecologist, surgeons, podiatrists, internists, grammatologists, neurosurgeons, paramedical personnel. With this subjective causes most often resulted in diagnostic and treatment defects, mistakes in administration and carrying out medical procedures (including irrational management of deliveries), defects in surgical treatment and organizational defects.
References:
1. Asadov D. A., Nazhmitdinov A. M., Sobirov D. M., Tagirov Ch. N. Quality of medical aid and E.M. // Medical Journal of Uzbekistan, 2004.- No. 3.- P. 12-15.
2. Blinova S. A., Ten S. A., Islamov S. E. Adrenal cortex response to prolonged administration of low doses of magnesium chlorate in rats // Morfologiia (Saint Petersburg, Russia). 2002.- Т. 121.- No. 1.- P. 27-30.
3. Giaysov Z. A., Kalish Yu. I., Kim L. A., Holmatov Z. B. Defects of medical care according to Forensic Medicine Expert Examinations materials // Surgery in Uzbekistan, 2000.- No. 4.- P. 102-107.
4. Holmatov Z. B. Some Forensic Medicine Aspects of professional activity of obstetriciancs-gynecologists. Author's abstract, Cand. of med. sciences - Tashkent, 2005.- 18 p.
5. Islamov S. Defects of organization in rendering medical aid // Medical and Health Science Journal. 2010.- Т. 3.- P. 72-76.
6. Indiaminov S. I. Morphological features of the human brain in different variants of fatal blood loss on the background of alcohol intoxication // Herald of Russian State Medical University. - M. 2011.- No. 5.- P. 63-66.
7. Indiaminov S. I. Tanatogenetic aspects of brain injury associated with hemorrhagic shock in human // Sudebno-meditsin-skaia ekspertiza. 2010.- Т. 53.- No. 3.- P. 4-6.
8. Indiaminov S. I. Medicolegal characteristic of the cerebrum in casw of hemorragic shock // Буковинський медичний вкник. 2013.- 70 p.
9. Kasimov S. et al. haemosorption In Complex Management Of Hepatargia: o27 (l1-1) // The International Journal of Artificial Organs. 2013.- Т. 36.- No. 8.- 548 p.
10. Malik A. et al. Hypertension-related knowledge, practice and drug adherence among inpatients of a hospital in Samarkand, Uzbekistan // Nagoya journal of medical science. 2014.- Т. 76.- No. 3-4.- 255 p.
11. Pigolkin Yu. I., Bogomolova I. N. Application of Principles of E.M. in expert practice // Forensic Medicine Expert Examination, 2004.- No. 6.- P. 3-6.
12. Rieck M., Moreland J. The Orpington Prognostic Scale for patients with stroke: reliability and pilot predictive data for discharge destination and therapeutic services // Disabil. Rehabil. 2005.- Dec. 15-27(23). - P. 1425-1433.
13. Sayit I. Damages to hypothalamus vessels in various types of blood loss on the background of acute alcohol intoxication // European science review. 2016.- P. 7-8.
14. Sergeyev Yu. D., Erofeyev S. B. Unfavourable outcome of rendering medical aid - M., Ivanovo, 2001.- 288 p.
15. Shamsiyev A. M., Khusinova S. A. The Influence of Environmental Factors on Human Health in Uzbekistan // The SocioEconomic Causes and Consequences of Desertification in Central Asia.- Springer, Dordrecht, 2008.- P. 249-252.
16. Исламов Ш. Э. Пробелы при производстве комиссионных судебно-медицинских экспертиз по профессиональным правонарушениям медицинских работников // Сибирский медицинский журнал (Иркутск). 2010.- Т. 96.- № 5.
17. Исламов Ш. Э., Шаматов И. Я. Судебно-медицинские аспекты дефектов медицинской помощи в оториноларинго-логической практике // Российская ринология. 2005.- № 2.- С. 144-145.
