KNOWLEDGE FOR ALL

ELL 4TH edition First on the medical side Beyond Davangere ELL think tank ELL Co-ordinators ELL For People

ETHIKOSFOR MEDICOS

Reach out to all stakeholdersSOCIAL CHANGE THROUGH KNOWLEDGE

Based on academics

BUT NOT AN ACADEMIC LECTURE

Knowledge unites like nothing else

A life beyond boundaries

OUR HEALERSGODS 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

I will practice my profession with conscience and dignity

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 brothersDeclaration

The Swiss Cheese Model of Accident Causation (Reason, 1990)Excessive cost cutting staffing reductionEquipment shortagesCommunication Staff Motivation Divided or confused accountability Deficient training programInexperienced X-Ray Tech Poor compliance to policies Poor Coordination & CommunicationFailed to review allergiesWrong X-ray marker usedWrong procedure performedFailures in theSystemPolicies/ProceduresAvailable ResourcesAccident & InjuryWrong Site Surgery Medication Error FallLatent ErrorsBarriers toAccidentsCommunication

Ethikos for MedicosEthicsConductMedical negligenceLegal statusQuality standardsConclusionStructure

Medical ethics is a system of moral principles that apply values and judgments to the practice of medicine As a scholarly discipline, medical ethics encompasses its practical application in clinical settings as well as work on its history, philosophy, theology, and sociologyMedical ethics

Medical Universe Patient At The Center

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 expressionsMedical 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 Percivals workMedical Ethics History

Ethics is a voluntarily self-imposed code of conduct by the medical profession.Medical ethics

Common framework four principals approach by Tom Beauchamp and James Childress in their book

Principles of biomedical ethics

ValuesinMedical Ethics

Respect for autonomy patient has the right to choose or refuse their treatment


Beneficence a practitioner should act in the best interest of the patient


Non maleficence first, do no harm


Justice-concerns the distribution of scarce health resources, and the decision of who gets what treatment (fairness and equality)


ValuesinMedical EthicsOther Values

Respect for persons the patient have the right to be treated with dignity

Truthfulness and honesty the concept of informed consent

ValuesAutonomy

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 non-maleficence

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 patients 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 casesTraditionally, 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

ConductIndian 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

ConductDuties 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

ConductDuties 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

ConductDuties of Patient

Duty to provide complete information/history/facts

Duty to follow instructions of Doctor

Duties to pay reasonable fee to the Doctor

ConductRights 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

ConductRights of Patients

SECOND OPINION RECORDS CONTINUITY COMFORT COMPLAINT COMPENSATION

ConductMEDICAL RECORDS Where we fail?Basis for patients care and for continuity in the evaluation of patients treatmentTo serve as documentation for reimbursementTo provide data for in medical education and clinical researchTo assist in protecting legal rights of all patient, doctor etc

ConductMEDICAL 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 SystemPrescribingDispensingAdministration

Medication ErrorMedication error leading to the death or serious disability of patient due to incorrect administration of drugs, for example:Omission errorDosage errorDose preparation errorWrong time error

Medication ErrorWrong rate of administration errorWrong administrative technique errorWrong patient errorPatient death or serious disability associated with an avoidable delay in treatment or response to abnormal test results

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

ConductPhysician Patient Relationship

THERAPEUTIC RELATIONSHIP

FORMAL RELATIONSHIP

(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

Communication

Communication Communication Age Medical practice depends upon doctor patient encounter. Relevant information for proper diagnosis & care Ensure patient co-operation and compliance

CommunicationThe 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 patients cooperation Famous heart surgeon from Houston Most patients are too embarrassed to ask the physician to repeat an instruction

CommunicationCommunication 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 and follow through medical advice lead to24% patients being grossly dissatisfied38% moderately compliant and 11% non-compliant

CommunicationStrategies 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

lNegligenceCurrent 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

lNegligence 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

lNegligenceInstances 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

lNegligenceInstances 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

lNegligenceContributory NegligenceUnreasonable conduct or absence of ordinary care on the part of the patient/attendant, which combined with doctors negligence contributed to the injury complained of, as a direct proximate cause and without which the injury would not have occurred

jNegligenceGenerally 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

jNegligence 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

jNegligence 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

jNegligence 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

jNegligence This is not the intention of law

Surgeon with shaky handsQuivering physician

jNegligence General Exceptions in Law Section 88

provides exemption not intended to cause death, done by consent in good faith for persons benefit.


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.


Saves from criminality certain communications made in good faith

jNegligence 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 acceptedBLAME CANNOT BE OVEREMPHASIZED

jNegligence Link 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

jNegligence Link 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

jNegligence Link 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

jNegligence Link 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

jNegligence Link between moral fault, blame and justice The test for determining as laid down in Bolams case holds good in its applicability in India

English tort law negligence Bolams Test If a doctor reaches the standard of a responsible body of medical opinion, he is not negligent

jNegligence The Final Opinion 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.

jNegligence The Final Opinion 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 Bolams test

jNegligence The Final Opinion 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


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


EVERY DOCTOR WHETHER AT A GOVT HOSPITAL OR OTHERWISE HAS THE PROFESSIONAL OBLIGATION TO EXTEND HIS SERVICES WITH DUE EXPERTISE FOR PROTECTING LIFE

jNegligence 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


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 medico-legal case

jNegligence 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

jNegligencePaschim Banga Khet Mazdoor Samiti 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 DrugConfusion over sound alike drugs / look-alike

Glynase ZynaseMetalarMetadacReglanReflin, ReflinAllegraEdegraGlimerGalamerFolinic acidFolic acidAcicotAciloc

..

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 HospitalsIn India: 163In 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 HealthcareEXPECTATIONSRendering acceptable quality care at affordable prices to patientsTimely access and care of patientsClear communication to the patientsBest practices for fixing appointment and service deliveryReliable diagnostic and laboratory support

Quality Aspects of HealthcareReliable support services (Canteen, ambulance, pharmacy, etc)Efficient in-patient services, with a goal towards zero errorsSafe and pleasant environmentTechnical competence of StaffCourtesy and attitude of Staff

NABH STANDARDS FOR HOSPITALSSecond Edition 10 - CHAPTERS63 - STANDARDS294- OBJECTIVE ELEMENTS

NABH STANDARDSChapters1. 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)

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)

NABH STANDARDS

1. Access, Assessment and Continuity of CareMatching patients requirements with organization's resourcesInitial assessment and periodic and regular assessments of patients in the hospital Laboratory servicesRadiology servicesTransfer and discharge protocols

2. Care of PatientsUniform care deliveryEmergency servicesAmbulance servicesBlood and blood productsIntensive care and HDUVulnerable patientsPediatric patients

Surgical patientsRestraintsPain managementRehabilitative servicesResearch activitiesNutritional therapyEnd of life care

3. Management of Medicine Pharmacy servicesHospital formularyStorage of medicationPrescription of medicationsDispensing of medicationMedication administrationNarcotic and psychotropic substancesChemotherapeutic drugsMedical gases

4. Patient Rights and Education Protects patient and family rightsProtecting beliefs, values and involvement in decision makingInformed consentsRight of information and education about healthcare needsInformation on expected costs

5. Hospital Infection ControlInfection control programSurveillance activitiesActions taken to prevent or reduce the risk of hospital associated infection(HAI)Facilities and resources provisionControl outbreaks of infectionBiomedical waste management

6. Continuous Quality ImprovementKey indicators Clinical structures, processes and outcomesKey indicators Managerial structures, processes and outcomes Quality Assurance programSystem for audit of patient care servicesSentinel events analysis

7. Responsibility of Management

Responsibilities of management are definedScope of services is documentedHospital managed in ethical mannerQualified and experienced individual heads the organizationPatient safety and risk management issues addressed

8. Facility Management & Safety

Laws, byelaws, rules and regulationsFacility for safety of patients, families staff and visitorsEquipment managementFire and non fire emergenciesSmoking policyDisaster management policyHazardous materials handling

9. Human Resource ManagementHR planning Training & developmentCredentialing Regular appraisals (Skills & knowledge assessment forms)Basic life support (BLS) education to all staffHealth needs addressedPersonal recordsDisciplinary procedure

10. Information Management SystemManagement of information needsMedical records Confidentiality, integrity and securityRetention of recordsMedical audits

BENEFICIARIES OF ACCREDITATIONPATIENTS Accreditation results in high quality care and patient safetyService delivered through credentialed medical staffRights of patients respected and protectedPatients satisfaction regularly evaluated

BENEFICIARIES OF ACCREDITATIONHOSPITALS Stimulates continuous improvementEnables hospitals demonstrate their commitment to quality careRaises the communitys confidence in the services provided by the hospital

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 - Hospitals

BENEFICIARIES OF ACCREDITATIONHOSPITAL STAFFSatisfaction as it providesContinuous 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 Institutions-Clean and Hygienic interior

Model Health Institutions-Patient friendly waiting room

Model Health Institutions-Citizen Charter

Model Health Institutions-Neonatal Corner

KAVERIPAKKAM PHC- FRONT VIEW

PHC PALLIKONDA

PHC PUDUPADI

KAVERIPAKKAM PHC Garden

Declaration of Alma-Ata International conference on primary health care, Alma Ata, USSR 1978

Health for All by 2000 Field issues

Field issuesAttitude towards patientshumanity, concernAttitude towards learning not to get degree or pass but to have proper knowledgeWrong diagnosis because of lack of knowledgeRefusal of mandatory laws to work in government hospitals after MBBSUnnecessary investigations show lack of knowledgePoor at spot diagnosis

Quality of medical students

Field issuesTo doctorsPatients transportation facilitiesTo hospitals- infrastructure, staffs, paramedical staffs, group D staffNot to be constructed at out skirtsAmbulance, communication to referral hospitalsNo timely supply of essential drugsPoor facilities provided at government hospitals

Field issuesImproper accommodation facilitiesRepeated transfersInterference of local politiciansPosting of master degree holders to rural areasOnly undergraduate doctors are necessary for rural areasHindrance by local authoritiesSecurity issues

Reasons for not working at government hospitals

Field issuesUnnecessary investigations show lack of knowledgePoor at spot diagnosisQuality of doctors from medical institutions has to be improved in their practical exposure and knowledgeThey need to establish a good doctor patient relationshipCase sheets incomplete documentation, discharge cards incomplete information

Medical colleges are factories producing doctors who are incapable

Field issues Negligence in budget at rural levels

Generation to generation medical services are deterioratingGovernment

Field issuesGood education system for doctors and paramedical staff and nursesPrimary care which isAccessibleAffordableAcceptableApproachableFund raisingCentral, from health tax, poor fund boxesTo improve

Field issuesNutritional food

Clean water

Disposal of waste

Environmental studies

Health educationPrevention is better than cure

NUTRITIONAL DIVERSITYMillions are chronically micronutrient malnourishedFacts: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

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 thats great for farmers its hardly an appeal to middle class consumers, particularly when they are being cautioned by opponents that the foods safety hasnt 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

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 Basic principle of law of torts

The Need for Consumer Law

Patient is a consumer now

Need has always been there

The need has always been there

CONSUMER PROTECTION LAW

Basic principles of law of consumerThe 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 commissionMore than 1 Crore

Who is a ConsumerA consumer is a buyer of goods or hirer of servicesBuys goods for a consideration which has been paid or promised or partly paid and partly promisedHires 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 CorporationDeduction made from his salary by the employer and deposited with the corporationAppellants wife admitted in ESI dispensary at Sonepat for treatment of diabetesHer condition deterioratedLater examined in a private hospWrongly diagnosed at ESI dispensaryComplaint filed under CPA

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.

Kishori Lal v. E.S.I Corporation II (2007) CPJ 25 (SC)

PRECAUTIONS AGAINST NEGLIGENCE Contact legal advisor

Never tamper with patients records

Always date clearly any addition to notes

Educate yourself further in the subject

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 recordsPRECAUTIONS AGAINST NEGLIGENCE

And Finally.Explain all treatmentGet consentAccurate notes of the unusualCare with risky patientsCorrect mistakes freeTell the patient about itAvoid excessive forceKeep contemporaneous records of all accidents and incidents

Report untoward incidents promptly to your OrganisationDo not act as an expert unless you are! And can be unbiasedKeep up to date with literature and new developmentsNot all unsatisfactory outcomes are negligenceSeek 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

ConclusionWe 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

LetsMakeIt hAPPEN

THANKS FOR THE RAPT ATTENTION

Will meet shortly

Ethics Committee bans doctor for negligencePankaj Rai Vs Fortis Hospital, BangaloreNegligence- 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)

Kishan Raos Vs Nikhil Super Speciality Hospital, HyderabadNegligence- Treated for Typhoid instead of malaria Patient diedSupreme court ordered that no expert opinion is required and directed the hospital to pay the compensation Compensation for wrong treatment

Javeed Vs C.S.I. Rainy Hospital, ChennaiNegligence- Operated on the wrong side for a herniaCompensation of one lakh paid the unnecessary suffering and agony.

Man gets Rs.1 lakh for medical negligence

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Documents

KNOWLEDGE FOR ALL