EDITORIAL

Adverse individual outcomes of healthcare

D F Wittenberg

MD, FCP (Paed) (SA). Editor. wittenbergdf@hmpg.co.za

The tragic case of paediatric oncologist Cyril Karabus and the publicity surrounding it have highlighted some of the emotive issues that arise out of adverse outcomes of healthcare.

When a patient dies or suffers an adverse event as a result of treatment or hospitalisation, the family's normal human emotions of shock, sadness and disappointment are easily and frequently projected into anger, culprit seeking and a desire for punishment and revenge. These are fairly common reactions that should be constructively channelled and worked through, if necessary with the help of appropriate counselling, while professional review and regulatory mechanisms ensure that any professional or healthcare system culpability is identified and dealt with.

The matter becomes problematic when a public figure or authority starts to champion emotional reactions expressed by the family or in the media as matters for legal investigation or prosecution before all relevant aspects of the case, including those of professional ethical behaviour and management, have been considered. After all, individual unexpected adverse reactions and outcomes arise as a consequence of a variety of circumstances that may include medical mishap, patient factors, healthcare system failure and indeed also malpractice, and certainly do not point to health worker culpability in each instance.

Medical mishap refers to an adverse event that occurs as a consequence of a medical procedure or therapy that is unpredictable in the individual case but not due to any omission or wrongdoing on the part of the health worker. Anaphylaxis after an injection or a fatal complication of a vaccination may even be a known risk, but it is usually unpredictable in the individual patient and is certainly not a priori due to health worker negligence. This type of adverse event is difficult to cope with for both the family and the health worker, as it is so unexpected, even though its risk of occurrence might have been known and mentioned when obtaining informed consent.

At other times adverse outcomes occur because the treatment or procedure itself was known to carry high risk but the only alternative was progressive disease or death without attempted treatment. These situations require detailed prior counselling and the patient's fully informed consent to avoid misunderstandings and accusations if things do go wrong.

Individual patients also certainly suffer adverse events because of health system failure or inadequacy. When a patient dies due to lack of oxygen because there were no back-up or replacement cylinders available, is the treating health professional to blame, or the whole chain of provisioning and maintenance?

Numerous examples exist of adverse outcomes due to health system failure ranging from failure to provide or maintain resources such as ambulances to lack of adequately trained staff, healthcare facilities and drugs. In such cases, responsibility for adverse outcomes cannot be delegated to the professional who has to deliver healthcare. There is no doubt about the system's culpability, but it becomes much more difficult to apportion punishable blame, and in any given country, culpability is obviously relative to what might reasonably be expected given a system's capacity and sophistication.

In the build-up to the National Health Insurance envisaged for South Africa, it has to be expected that adverse outcomes of systemic healthcare failures will be closely scrutinised.

The most emotive adverse outcome is that due to medical malpractice, defined as the health professional's failure to adhere to recognised norms and guidelines of patient management. This may include acts of commission or omission and extends to culpable ignorance in respect of life-threatening conditions. It could be argued that much bad practice relates to inadequate training and supervision and insufficient continuing professional development. Over and above their doctors' actual management, however, patients frequently experience a perceived lack of caring and failure to communicate honestly and openly as most hurtful. This is the type of adverse outcome that should be wholly preventable, and for which the responsible party has to accept the consequences of professional censure, legal prosecution and civil litigation.

Everything possible should be done to minimise the risk of adverse outcomes of patient care, but in all situations honest disclosure and open communication will help to reduce the pain, the anger and the confrontation.

We are happy to see an increasing number of submissions to SAJCH. Inevitably, this leads to delays in seeing your articles in print. For this we are sorry, but we hope that this issue's mix of research studies and illustrative case reports makes interesting and varied reading.

Good luck.