醫療糾紛之解決第一頁，共29頁。Toallhealthcareprofessionalswhodidtherightthing,whendoingtherightthingwasveryverydifficult.

JohnBanjaMedicalErrorsandMedicalNarcissism第二頁，共29頁。Whatisrightinmedicalmalpracticecases?臺灣醫療糾紛爭訟中，病人敗訴率高醫界常見的說法：若該件事件，醫師有過失，早就理賠了；故上法院的案件中，本就是醫師沒有過失的情形居多質疑：除非明顯過失，否則因為醫療的高度專業性，一般人根本無從去爭執醫師的過失。掩飾過失比承認過失容易舉例：一婦產科醫師於接生後天忘記將置放於產婦陰道中的紗布取走，間隔達42天之久，但醫師仍振振有詞的主張，其有醫療之必要性。第三頁，共29頁。想想這些案例：小明放學後在家的附近和弟弟打棒球，弟弟投出一個又直又軟的慢速球，小明奮力一揮，「砰」，竟將鄰居陳太太家的玻璃打破了。但此時陳太太正好全家都不在家。你是小明的爸爸，小明告知你此事，你會教他怎麼作？第四頁，共29頁。案例二：李先生在經過多年的辛勤工作後，存了一筆錢。他的願望就是將家中又窄又暗的小浴室改裝成五星級飯店般乾濕分離的豪華空間。經過3星期的施工，一家人都很滿意最後的成果。洗澡也成了李家一件愉悅的事。但8月的一場颱風過後，新浴室的馬桶卻不時的阻塞。找人檢修的結果是：當初包商將用剩的水泥就直接倒入馬桶中，以致於造成水管狹窄，遇有大雨便會阻塞。李先生此時豁然瞭解原來住在樓下的王小姐其天花板漏水的原因。但王小姐只是房客，房東林先生則長期定居國外。第五頁，共29頁。案例三甲為某大學的研究生，為賺取學費下課後至麥當勞打工，10點打烊後再回研究室作實驗。某日半夜騎車返家的途中，因為太過疲倦，一個閃神，輪胎似乎撞倒東西。下車一看，竟然有一個人倒臥血泊之中，其渾身酒氣沖天，但不幸已經死亡。甲萬分驚恐，但並不明白究竟此一事件的原因為何？是甲將其撞死的嗎？還是該人原本就受傷躺在路上？還是甲只不過撞上了一個屍體？此時夜深人靜，四下無人。甲相當確定事發當時沒有任何目擊證人。甲該怎麼作？第六頁，共29頁。案例四年輕的B小姐患有輕度精神分裂癥，並有自殺傾向。曾多次自殺，但都送醫急救後存活。一日深夜12點左右，B小姐打電話給家人，告知其在鄰近的公園，已經吞食了200顆的安眠藥。家人聞訊急忙將B小姐送往附近的H大醫院急診室。急診醫師趕忙替B小姐催吐，洗胃；過程中，因為B小姐情緒激動，所以用束縛帶將其固定在病床上，未料護士不注意，液體流入B小姐的氣管中，導致B小姐呼吸困難，進而休克。雖急救後恢復生命跡象，5天後，B小姐死於吸入性肺炎。第七頁，共29頁。誠實最上策？前述四個例子，你的答案是什麼？想想你是受害人的話，你希望答案是什麼？若你是法官，你認為係爭當事人之間正當的舉動是什麼？在一個公義的社會中，前4個案子應該如何解決？第八頁，共29頁。為什麼認錯這麼難？歸咎文化使得認錯比文過飾非更困難Theoldparadigmofblamingandpunishingindividualsledtooverrelianceonflawlesspersonalperformanceandtothehidingofmistakesoutofshameandfeariftheyoccurred.AlbertWuconductedananonymousstudyof114houseofficersregardingtheirmostsignificantmistakes.Only54%haddiscussedtheirmistakewiththeirattendingphysician,andonly24%toldthepatientsandfamilies.WuAW.Dohouseofficerslearnfromtheirmistakes?JAMA.1991,265:2089-2094第九頁，共29頁。Patients'andPhysicians'AttitudesRegardingtheDisclosureofMedicalErrorsThomasH.Gallagher,MD;AmyD.Waterman,PhD;AlisonG.Ebers;VictoriaJ.Fraser,MD;WendyLevinson,MD

JAMA.

2003;289:1001-1007.

Context

…littleisknownabouthowpatientsandphysiciansthinkmedicalerrorsshouldbediscussed.Objective

Todeterminepatients'andphysicians'attitudesabouterrordisclosure.

Design,Setting,andParticipants

Thirteenfocusgroupswereorganized,including6groupsofadultpatients,4groupsofacademicandcommunityphysicians,and3groupsofbothphysiciansandpatients.Atotalof52patientsand46physiciansparticipated.第十頁，共29頁。.

Results

Patientswanteddisclosureofallharmfulerrorsandsoughtinformationaboutwhathappened,whytheerrorhappened,(x)howtheerror'sconsequenceswillbemitigated,andhowrecurrenceswillbeprevented.(x)Physiciansagreedthatharmfulerrorsshouldbedisclosedbut"choosetheirwordscarefully"whentellingpatientsabouterrors.Althoughphysiciansdisclosedtheadverseevent,theyoftenavoidedstatingthatanerroroccurred,whytheerrorhappened,orhowrecurrenceswouldbeprevented.

第十一頁，共29頁。錯誤告知對醫病雙方的心理意義醫師的認錯與道歉對受到醫療傷害的病人而言，有治療上的意義，但是醫師們對未來醫療糾紛的恐懼使得他們傾向文過飾非。一個有害的錯誤發生了，犯錯的人自己也有心理上的創傷需要情緒支持，認錯，道歉，並得到病人的原諒對當事醫師而言，也有治療的意義。病人原諒醫師對病人本身也有治療意義第十二頁，共29頁。現狀的問題醫療機構有提供專業服務與情緒支持，協助發生醫療錯誤的醫師如何與病人溝通，討論錯誤嗎？醫學教育有訓練醫師，如何與病人溝通，討論錯誤嗎？第十三頁，共29頁。Subtractinginsultfrominjury:addressingculturalexpectationsinthedisclosureofmedicalerror

NBerlingerandAWWu…whilephysiciansmayexpressaneedforself-forgivenessaftermakingerrorsandshouldbeawarethatpatientsmayalsorelyuponforgivenessasameansofdealingwithharm.…learninghowtodiscloseerrors,apologisetoinjuredpatients,ensurethatthesepatients’needsaremet,andconfronttheemotionaldimensionsofone’sownmistakesshouldbepartofmedicaleducationandreinforcedbytheconductofseniorphysicians.第十四頁，共29頁。CommunicatingWithPatientsAboutMedicalErrorsAReviewoftheLiterature

KathleenM.Mazor,EdD;StevenR.Simon,MD;JerryH.Gurwitz,MD

ArchInternMed.

2004;164:1690-1697.Background

Theobjectiveofthisstudywastoreviewtheempiricalliteratureondisclosureofmedicalerrorswithrespectto(1)thedecisiontodisclose,(2)theprocessofinformingthepatientandfamily,and(3)theconsequencesofdisclosureornondisclosure.Methods

Wesearched4electronicdatabases…and[f]rommorethan800titlesreviewed,weidentified17articlesreportingoriginalempiricaldataondisclosureofmedicalerrorstopatientsandfamilies.第十五頁，共29頁。.

Results

…patientsandthepublicsupportdisclosure.Physiciansalsoindicatesupportfordisclosure,butoftendonotdisclose.Wefoundinsufficientempiricalevidencetosupportconclusionsaboutthedisclosureprocessoritsconsequences.Conclusions

Empiricalresearchondisclosureofmedicalerrorstopatientsandfamilieshasbeenlimited,andstudieshavefocusedprimarilyonthedecisionstageofdisclosure.Fewerhaveconsideredthedisclosureprocess,theconsequencesofdisclosure,ortherelationshipbetweenthetwo.Additionalresearchisneeded….第十六頁，共29頁。BenKolb之死BenKolb,7yearsold,arrivedatMartinMemorialHospital,inStuart,Fla.,inDecember1995.Thiswastobethethirdearoperationontheseven-year-oldBen.Hisdoctorwantedtoremovescartissuethatwasleftfromthepriorsurgeries,atages2and5.Benwasgivengeneralanesthesia,andabout20minuteslaterittookfulleffect.Hissurgeonwashandedwhateveryonethoughtwasasyringeoflidocaine,alocalanesthetic,whichreducesbleeding.HeinjecteditinsideandbehindBen'sear.Momentslater,fornoapparentreason,Ben'sheartrateandbloodpressureincreasedalarmingly.Dr.GeorgeMcLain,ananesthesiologistonstandbyforemergencies,wassummoned.McLainhelpedtostabilizethechild,butashorttimelater,Ben'sheartrateandbloodpressuredroppedprecipitously.Foranhourand40minutes,franticdoctorsperformedCPRontheboy,knowingitwasfutile.第十七頁，共29頁。醫師的眼淚Morethanayearlater,thememoriesarefresh,andMcLainsitsatlunch,cryingashespeaks.Theotherdinersstare,buthemakesnoattempttohidehistears.HowlongwouldhehavekeptuptheCPR?"Ifitwasmykid,Iwouldwantthemtokeeptrying,"hesays."Ithinkwewerenevergoingtostop."第十八頁，共29頁。告知不幸消息（Whathappened?)

Ben'sheartdidbegintobeatagain,andhewastransferredtoMartinMemorial'sintensivecareunit.Thesurgeon,whoknewBensincehewasababy,wewithMcLaintotalktoTammyKolb."Therehasbeenaseriousproblemwithyourson,"McLainrememberstellingthewoman."Hisheartstopped.Wehadtorestarthisheart.Heisextremelycritical,inacoma-likestate."

Benremainedinacomafornearly24hours.Hisparentsandoldersisterremainedathisbedsideastheirfoganddenialslowlylifted.Thenextday,theyagreedthathisventilatorshouldberemoved,andhewasdeclaredbraindead.第十九頁，共29頁。調查開始（Whatactuallyhappen?)First,thehospital'sriskmanager,DoniHaas,hadallthesyringesandvialsusedonBen,lockedaway,thensenttoanindependentlaboratoryforanalysis.Second,HaaspromisedBen'sparentsthatshewasgoingtofindthemananswer,iftherewasone."

Therewas.Testsshowedthattherehadbeenamix-up,amistake,ahumanerrorinasystemthatmadethaterrormorelikely.BenKolb,labreportsshowed,wasneverinjectedwithlidocaineatall.Thesyringethatwassupposedtocontainlidocaineactuallycontainedadrenaline,ahighlyconcentratedstrengththatwasintendedonlyforexternaluse.第二十頁，共29頁。何以錯誤會發生？ProcedureintheMartinMemorialoperatingroomatthetimewasfortopicaladrenalinetobepouredintoonecup,madeofplastic,andlidocainetobepouredintoacupnearby,madeofmetal.Thelidocainesyringewasthenfilledbyplacingitinthemetalcup.Itwasaprocedureusedalloverthecountry,awayofgettingdrugfromcontainertooperatingtable.Butitisaflawedprocedure,thehospitallearned.Itallowsforthepossibilityforthesolutiontobepouredintoordrawnoutofthewrongcup.Instead,acap,calledaspike,couldbeputonthevialoflidocaine,allowingthedrugtobedrawndirectlyoutofthelabeledbottleandintoalabeledsyringe.Theeliminationofonestepeliminatesoneopportunityforthehumanfactortogetintheway.第二十一頁，共29頁。告知錯誤HaasreceivedthelabresultsthreeweeksafterBendied.Thefamilyhadhiredandattorneybythen,andHaasandMcLaindrovetwohoursandmetwiththeKolbsatKrupnick,Campbell,Malone,Roselli,Buser,Slama&Hancock.Afinancialsettlementwasreachedbynightfall,butneithersidewillconfirmtheamountpaidtotheKolbs.

Afterthepapersweresigned,thefamilyaskedforachancetotalktothedoctorsatthehospital.ThefirstthingBen'sfather,Tim,didwhenheenteredtheemotion-filledroomwastohughisson'ssurgeon.Thencamethetorrentofquestions,questionsthathadkepttheKolbsawakeatnight,questionsthey