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Iatrogenic Harm

Prof B. H. Ali, Ph. D.

Department of PharmacologyCOMHS, SQU

http://www.nap.edu/catalog.php?record_id=9728

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Iatrogenic Diseases

- “Iatro” or iatros means Doctor - “Genic” means :Caused by- Iatrogenic diseases are doctor - created illness- Iatrogenesis is inadvertent “inattentive”adverse

effect or complications caused by medicaltreatment or advice.

- Iatrogenesis can be due to other health

professionals (e.g. nurses pharmacists etc!- Iatrogenesis can also be due to therapy "ithtraditional (alternative! medicines

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History of Iatrogenic Diseases

- #otential damaging effect of a healer$s actions has beenrecogni%ed since ancient time.“irst !o no harm& is animportant clause of medical ethics ' iatrogenic illness ordeath caused purposefully or by avoidable error or

negligence on the healer$s part became a punishableoffence in many civili%ations..

- ith the development of scientific medicine in the )*th century iatrogenic illness or death became more easilyavoided. ith the discovery of antiseptics anesthesiaantibiotics and ne" and better surgical techni+uesiatrogenic mortality decreased enormously. 

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History of Iatrogenic Diseases

- ,/0 12 1345678 9;?@ A

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History of Iatrogenic Diseases

- - A

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http:ŠŠ""".youtube.comŠ"atch‹vŒguC)ŽI‘’

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Iatrogenesis literature

- Iatrogenic !isor!ers in mo!ern neonatology? a foc@son safety an! @ality of care. Clin Perinatol. E FG?

- Iatrogenic sJin inK@ry in hospitaliLe! patients. Clin

  Dermatol. E?N.

Iatrogenic laser complications. Clin Dermat. ,, N 

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  Glossary: General Definitions Found in Studies andDiscussions of Medical Errors

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Definitions

- A!erse eent: ’n inury or complicationcaused by medical management that prolongshospital stay or produces lasting disability ordeath ( of ’ are due to negligence 610(!

- Amelioratie A!erse eent (’’!: ’n inury of"hich the severity or duration could ve beenreduced if different action had been ta–en (e.g.

se—ual dysfunction lasting for several months"hile ta–ing ˜I for depression!

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Iatrogenic Diseases

- ™he rd Žost šatal Disease in the ›’‹‹- Close to œ***** people die every year

from plane crashes‹

- ) millions Š year die due to iatrogenesis"orld"ide

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PossiRle ca@ses of iatrogensis

- Žedical error - ide effects of treatment

- Drug interactions

- ‘egligence fa@lty proce!@re transfusion- unnecessary treatment for profit

-  ’n—iety or annoyance in the physician in

relation to medical procedures Š treatments- une—amined instrument design

- Chance illegibleŠ "rong prescriptions etc

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Iatrogenic Diseases incl@!e?

- Inecting "rong medication (e.g. antispectics!- Complications after surgical procedures e.g.hernia after a gastric bypass Urogenital fist@la or accidental traumatic amp@tation of the glans

penis during ritual circumcision .- ome are less obvious and re+uires detailed

investigations to identify (e.g. comple— druginteractions!

-  

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Iatrogenic Dr@g Interactions DIsT

-  ’dverse effects can be caused by DIs e.g. "hen a Dr. or pharmacist fail to chec– for all

drugs a patient is ta–ing ' prescribe ne"

ones that interact agonistically orantagonistically HIVW O XYAMPZXSžŸ

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Iatrogenic disease (I. D.! in the elderly

- šor prevention of I.D identify patients athigh ris–

- ˜is– factors of I.D. in the elderly include:

- œ. Drug induced I.D.- ). Žultiple chronic diseases

- . Žultiple physicians

- ¡. ospitali%ation- ¢. Žedical or surgical procedures

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Me!ical Xrrors MXT

- Doctors should consider the best interests of theirpatients and [!o no harm$.

- #reventable adverse effect of care "hether or not itis evident or harmful to the patient including an

inaccurate or incomplete diagnosis or treatment of adisease inury syndrome behavior infection orother ailment.

- Ž can be individual human error but are often

systems - based and in many cases are avoidable.- ˜eporting and learning from Ž improves the

safety of patients.

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MXs s AXs

- Žust differentiate bet"een MXs ' adverse events( ’s!.

- Žost Žs are not ’s (they do not harm patients! 'most ’s are not Žs ' are therefore not

preventable.- AX? An inK@ry or complication ca@se! Ry me!ical

management that prolongs hospital stay orpro!@ces lasting !isaRility or !eath.

- MX? Any act that \ill, Rase! on c@rrentlyaailaRle information, s@Rstantially increasesthe risJ for an a!erse eent.

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Xthical ]ationale for XrrorDisclos@re to patients

- Informe! Consent: rror disclosure is a form ofinformed consent conveying important information topatients that they need to ma–e informed decisionsabout their subse+uent medical care.

- r@thelling: Important to disclose errors as a form oftruth telling. rrors should be disclosed even if theinformation is not essential to informed decision-ma–ing.

- ^@stice an! airness: £ustice also support errordisclosure as such information is often a prere+uisite toa patient accessing compensation for their inuries.

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Issues related to medical errors

- Žany Drs. "orry that disclosing errors to patients "illprecipitate la"suits. ’ctually patients are more li–ely tosue Drs. "hen communication brea–s do"n fear ofmalpractice suits "ill be a significant barrier for opendiscussion about errors "ith patients.

- Drs. can get mi—ed messages from different sources "hoe—plicitly say Drs. should not apologi%e to patients as anapology is an admission of fault. o" to handleapologies effectively is a –ey issue for error disclosure.

-

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_hat patients sho@l! fin! inan error !isclos@re

- —plicit statement than an error occurred- hat the error "as ' its clinical

implication

- hy the error happened

- o" recurrence "ill be prevented

-  ’n apology

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Iatrogenesis !@e to mis!iagnosis

- Žisdiagnosis can lead to iatrogenesis e.g.diagnosis "ith a false psychological or psychiatriccondition (e.g. bipolar disorders!.

- Iatrogenic factors in chronic pain patients include

over-investigation inappropriate information andadvice given to patients as "ell as mis!iagnosisover-treatment and inappropriate prescription ofmedications.

- ubstance abuse comorbidities can producesymptoms similar to other psychiatric disordersleading to mis!iagnosis.

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‘osocomial Infections (‘Is!- ‘I is an Iatrogenic infection that is ac+uired in

hospital ' "as not present or incubating onadmission.

- ‘Is can be caused by unclean or inade+uately

sterili%ed needles surgical instruments andungloved hands to perform medical or dentalprocedures e.g. I¤ catheter or hepatitis ¥ or Cinfection can be transmitted by dentists or

surgeons.

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#harmcogentics ' iatrogenic disease

- Pharmacogentics studies differences in the metabolicpath"ays that affect individual responses to drugs bothin terms of therapeutic effect as "ell as adverse effects.

- ™here are many e—amples and some present as medicalemergencies. —amples of pharmacogentic dosorders:

- œ. Žalignant hyperpyre—ia (halothane!

- ). G¦#D deficiency (hemolytic anemia ' antimalarials!

- . §actic acidosis (metformin!

- ¡. epatic adenoma (oral contraceptives!- ¢. ¥radycardia (beta bloc–ers e.g. metoprolol! -

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Preention of Me!ical Xrrors

- hese help preent errors:-  ’! ffective reporting system

- ¥! ’nalysis of these reported events

- C! Improved system of care

- D! §earning from the ’š™¨ CI‘C(including uman šactors ngineering!

- ! ™echnology including information technology

physician order entry design of medical devices etc- š! ‘eed for ¤ID‘C on "hat "or–s to preventerrors

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Potential Strategies for Coping _ith

Me!ical MistaJes. ProRlem ` foc@se!

. Xmotion foc@se!

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ProRlem ` foc@se! Strategies

-  ’cceptance of responsibility- Consultation to understand

  nature of mista–e

- Consultation to correct

mista–e

- #lanned problem-solving

-  (e.g. obtaining e—tra training!

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Xmotion ` foc@se! Strategies

- #ursuance of social support- Disclosure to colleague friend or spouse

- Disclosure to patient

- motional self-control (e.g. repressingone©s emotional response!

- scape avoidance

- Distancing- ˜eframing of mista–e (e.g. recogni%ing it as

inherent in practicing medicine!.

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Common Changes in practicefollo\ing mistaJes

- AT Constr@ctie Changes

- BT Defensie Changes

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Constr@ctie Changes in practicefollo\ing mistaJes T

- Increasing vigilance:- a! paying more attention to details

- b! confirming data personally

- c! changing data organi%ation

- d! ordering additional tests asappropriate

- e! improving screening for disease

- f !Improving communication "ith patients

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Constr@ctie Changes in practicefollo\ing mistaJes T

- Increasing information see–ing by ’ªI‘G ’D¤IC and by ˜’DI‘G.

- Improving self-pacing

- Improving communication "ith staff 

- upervising others more closely

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Defensie Changes inpractice follo\ing mistaJes

- ¥eing un"illing to discuss error 

-  ’voiding patients "ith similar problems

- «rdering additional but unnecessary tests

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A!erse effects associate! \ith accines- ¤accines are associated "ith un"anted effects (no effects

to severe brain damage!.-  In the past these adverse effects "ere due to product

defects.

- ¤accines are generally safe but can cause someproblems in a fe" individuals receiving them.

- Doctors are often accused of do"nplaying the ris–s ofvaccination ' claiming that childhood immuni%ation iscompletely safe and that there is no reason to "orry

"hen children get immuni%ed.- ™hese concerns should be discussed as denying or

dismissing them may lead parents and patients to see–advice from uninformed sources.

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hali!omi!e !isaster, N™halidomide "as described as a sedative "ith minor side

effects in œ¬¢¦.- It "as used as antiemetic and an—iolytic in pregnant

"omen.

- «nly ) years after thalidomide$s launch as Contergan in

Germany it$s alleged lac– of to—icity came into +uestion"ith reports of the drug causing numerous side effects.hortly thereafter thalidomide "as connected "ith anepidemic of deformities (limb truncations and

microphthalmia.! in children "hose mothers had ta–enthe drug during pregnancy.

- ™halidomide$s teratogenic effects led to the institution orstrengthening of some regulatory bodies in ›ª ' ›’.