|Year : 2015 | Volume
| Issue : 7 | Page : 20-24
Medical incidents in developing countries: A few case studies from Nigeria
Department of Maxillofacial Surgery, University of Teaching Hospital, Enugu, Nigeria
|Date of Web Publication||1-Dec-2015|
F N Chukwuneke
Department of Maxillofacial Surgery, College of Medicine, University of Nigeria Teaching Hospital, Enugu
Source of Support: None, Conflict of Interest: None
| Abstract|| |
The moral worth of a clinician's, action in patients' management depends exclusively on the moral acceptability of the rule of obligation to duty on which the clinician acts. Since every rational being thinks of him or herself as an end, all people must act in such a way that they treat humanity, whether in their own person or in the person of another, always as an end and never simply as a means. A duty of care is, therefore, paramount in the relationship between clinician and patient. While litigation in healthcare system is rapidly increasing globally, which affords individual explanation and compensation for perceived wrong diagnosis and treatment; it is still rudimentary in Nigeria. This default position has made most health care providers indifferent in the presence of gross clinical negligence and medical errors. Though most Nigerians may be aware of their rights to institute legal action in situations such as, negligence with serious harm or death, but, the socioeconomic factors, cultural, and religious notions among other reasons within the society often makes litigation impossible for an individual. Attributing every medical adverse event in the course of treatment as "God's Will" and the saying "It's God's Time" for every death among most African people has also become a great impediment to curbing clinical negligence in our environment. This paper presents a few case studies from author's experience and complaints from patients during clinical practice.
Keywords: Clinical negligence and medical errors, developing countries, medical practice, Nigeria
|How to cite this article:|
Chukwuneke F N. Medical incidents in developing countries: A few case studies from Nigeria. Niger J Clin Pract 2015;18, Suppl S1:20-4
| Introduction|| |
Clinical negligence constitutes an act or omission by a clinician in which the treatment provided falls below the accepted standard of care resulting to injury or death of the patient. On the other hand, medical errors occur when a clinician chooses an inappropriate method of care or improperly executes an appropriate method of care. Clinical negligence and medical errors often has a wide spectrum of indications ranging from misdiagnosis, wrong decisions and treatment method, abandonment of patients, prescription errors, medical or surgical complications, all of which may result in increased morbidity, permanent injury or death.
Medical errors are often described as human errors in healthcare with element of negligence either from the system flaws or character flaws. Either way, the fact remains that in both cases the duty of care is defective. Variations in healthcare provider training and experience as well as failure to acknowledge the prevalence and seriousness of medical errors also increase the risk.,,, A duty of care requires a certain degree of prudence and caution by the attending clinicians in order to maintain the appropriate standard of care while treating a patient. Notwithstanding that errors in clinical practice may be inevitable part of human factor even among the most qualified and meticulous professionals,, some medical errors are traceable to ignorance on technical matters that any person practicing the profession is supposed to be familiar with. Therefore, clinicians should at all times carry out their work with a moral obligation to their duty in order to minimize or prevent avoidable occurrences. Most often errors may occur as a result of system flaws and not character flaws, especially in a developing and depressed economy but clinical negligence should be accepted as character flaws. A duty of care is, therefore, paramount in the relationship between clinician and patient.
Since clinical negligence and medical errors interferes with the quality of care received by patients, and deny them their fundamental right to the highest standard of health care; there must be regulations to checkmate it. Countries have different standard and regulations in medical practice with formation of several regulatory bodies such as the Nigerian Medical and Dental Council (NMDC) in Nigeria and Health Professions Council of South Africa. The duty of these bodies is to protect members of the public by ensuring that doctors and other health care givers are properly qualified that they perform their services to patients with competence and diligence, and that they observe at all times high moral and ethical standards while attending to their patients. A legal duty exists whenever a hospital or health care provider undertakes care or treatment of a patient. This duty is, therefore, breached when the health care provider failed to conform to the relevant standard of care resulting in injury or death. When a practitioner acts in a manner that is contrary to the generally accepted standard of professional care it consists negligence because it negates the rule of optimal care for the patient.
| Clinical Negligence and Medical Errors in Nigeria - an Overview|| |
Nigeria has the largest population in Africa with over 250 ethnic groups and more than 510 languages. This has made the country a complex society with different cultural and religious practices which also reflects on the people's attitude and understanding of their health matters within the same country. Just as seen in some African Societies, the Health Care Systems of Nigeria emerged from colonial medical services that emphasized costly high-technology, urban-based, and curative care. When Nigeria became independent in the 1960, she inherited health care systems modeled after the systems in industrialized Western nations that colonized it. The chronological trends in the health care system inherited from the colonial masters probably gave the general perception of seeing health care providers, especially doctors as all-knowing in medical care. This default position often projects clinicians to paternalistic tendencies and stand-point which often leads to increasing occurrence of clinical negligence and errors in clinical practice because patients do not have room to be involved in their health management.
Inequitable distribution of health care facilities, inflationary cost of health care services, and inaccessibility of existing infrastructure in Nigeria are some of the serious challenges to the survival of an average Nigerian which also affects our health care system. There are everyday emergencies that have ended in fatality because of the down payment required before treatment even in public hospitals. The public hospitals in Nigeria have a greater percentage of death rate and unreported malpractice incidents. According to Iberiyenari  it is not that the private hospitals in the country own more sophisticated health care facilities than the public sectors, but the practitioners in these private hospitals are more hospitable than the ones, we have in the public hospitals; thus patients prefer going to private hospitals where they will be well attended to as long as they have the money. The patients who patronize the public hospitals in Nigeria, are mostly the less privileged and if there is any case of negligence they may not have the means to file legal actions against the hospital or medical practitioner. In an environment where ignorance and poverty is common-place people's fundamental rights are often violated, and most patients do not have the means to pursue cases of negligence and errors by practitioners in the course of their treatment. Consequently, most Nigerians have greatly suffered the consequences of medical negligence in silence.
A research carried out by the author  shows 57.5% of Nigerians have been judiciously patronizing the health centers while 61.1% were disposed to visit traditional healers/local midwives in a questionnaire based survey. One of the reasons given by the respondents for the preferred choice of the visit was the poor organization of health care services in our health centers [Figure 1]. In the same vein, of the 32 respondents interviewed, 23 (71.8%) complained of lack of drugs in the health center as their reasons for not patronizing the center while 28 (87.5%) were concerned about nonavailability of health care givers in the health centers. On their assessment of the health care center meeting their health needs, 29 (90.6%) were of the opinion that ineffective treatment and lack of care has been an impediment to people visiting health center except when other alternatives have failed. Since good quality of health care delivery encourages individual to seek for health care promptly, clinicians and healthcare providers should because of their obligations endeavor to deliver safe and ethically sound clinical care always even in the face of adverse economy. Clinicians should be aware of the existence of the basic human rights and equity considering the values and dignity of patients before making decisions or taking actions that may affect them. Responsibility is, therefore, the fundamental of ethical decisions in clinical practice. The cases studies presented here are derived from author's experience in clinical practice and complaints from some patients in Nigeria. These cases were not litigated, and there were no medical liabilities established.
|Figure 1: The influence of health care service organization on health seeking behavior (author's report on 161 respondents, April 2009)|
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| Case Presentation|| |
Case 1: Medical error
A 27-year-old woman had a upper right jaw swelling following a poorly healed extraction site. The swelling extended to her right upper eye-lids prompting her seeking for a doctor (maxillofacial surgeon) attention. The doctor suggested and carried out a biopsy to determine the histopathological status of the lesion before performing further treatment. The biopsy was performed, and the specimen was sent to a certified oral pathologist. The result confirmed a case of fibrosarcoma (cancer) which was sent to the attending surgeon. The surgeon was in the dilemma of the next treatment options since the result came out as a cancer case and the alternatives considered were radiotherapy and surgery. The radiotherapy was to commence before the surgery, but the doctor on a second thought, decided to carry out the surgery before radiotherapy. During the surgical procedure, the surgeon observed that the lesion was not presenting such as a cancerous lesion and promptly called the oral pathologist for second assessment and thereafter the lesion was confirmed noncancerous (giant cell lesion).
Cases 2: Medical error
A 17-year-old boy reported to the oral and maxillofacial surgery unit with 2 months history of left mandibular swelling following tooth extraction. The patient had gone to a nearby public hospital when he noticed a little swelling at the buccal aspect of the first molar on the lower right jaw. A peri-apical radiograph was taken by the attending dental surgeon after which he carried out an extraction of the tooth without checking and understanding the X-ray findings. A week later, the swelling became bigger prompting the patient going back to the dentist who attempted aspirating the swelling. Within the next few days, the swelling had grown bigger with serious pain, discomfort, and facial distortion. The patient at this point had to seek a second opinion. On seeing the patient, the maxillofacial surgeon looked at the previous X-ray and observed the widening of the periodontal ligament that suggested a cancerous lesion (sarcoma) which the dentist could not see. Biopsy result confirmed osteogenic sarcoma. At this stage, the lesion was inoperable. The patient died 3 weeks after commencement of chemotherapy.
Case 3: Clinical negligence
An anesthetic doctor was in a haste to intubate a patient for a major surgery. Unfortunately, the patient he was attending to and trying to intubate was a difficult case for easy intubation because of the involvement of the lesion in the head and neck region. The patient became seriously traumatized both orally and intra-nasally without progress getting him intubated, prompting the surgeon to advice the anesthetics to resuscitate the patients so that tracheotomy could be carried out to facilitate the surgery since it was obvious that he could not intubate the patient in a conventional way. The anesthetic doctor assured the surgeon that everything was perfect that he could go ahead and perform the tracheotomy that he was going to pick something and come back. Not minding the vehement protest from the surgeon he left the patient. On trying to perform the tracheotomy, the surgeon observed that the patient was no longer breathing and all attempt to revive the patient was fruitless.
Case 4: Medical error/malpractice
An elderly woman of about 75-year-old had a dentofacial infection and the children ignorantly took her to a general medical practitioner who admitted her in his private hospital. The general practitioner did not refer the patient to a specialist instead continued giving the patient treatment. One week after the infection continued spreading resulting to cellulitis yet the doctor did not think wise to refer the patient. All these time the family was spending money with no pleasing result while the woman was languishing in agony. When it became obvious that the woman's health was deteriorating, the doctor without any clinical investigation called the patients family and told them to go and prepare for their mother's burials because she has cancer of the oral cavity and will die in a week's time. When she was taken away from the hospital and with much moaning every day, as result of severe pains she was passing through, someone suggested and they saw a dentist. The dentist then referred her to a maxillofacial specialist surgeon who made a clinical diagnosis of dentofacial infection with cellulitis and initiated adequate treatment immediately. The woman survived and is still alive as at today.
Cases 5: Medical error/negligence
A case of a young mother on her first delivery was discharging feces through her virginal orifice as a result of improper episiotomy and repair performed by a supposedly trained mid-wife in a private hospital. The attending gynecologist was absent when she delivered, and the mid-wife was said to be experienced in performing the procedure but this time a terrible mistake occurred. The husband took her wife to the hospital for correction of the anomaly only to be told they have to pay a lot for the damages and harm the hospital caused for the woman. The husband vehemently refused on the condition that they caused her wife's problem as a result of their carelessness. They abandoned the patient without medical attention prompting the husband to threaten for a legal action against the hospital. Of course, this made the hospital to reverse their decision and pacify them.
Case 6: Negligence/medical error
A young woman of 21-year-old in her first pregnancy was under the care of a private obstetrician but for the advice from relations decided to deliver her baby in a teaching hospital to be sure adequate care was taken. When the labor started and sustained for a longer time cesarean section (CS) was decided. Unfortunately, the attending obstetrician was not available and instructed the younger inexperience resident to carry out the surgical procedure. She was taken to the theater and a CS was performed. Not only did the woman lose the baby boy, but, she was yet to receive a shocker in her life-time. After several years the woman could not conceive again. Several investigations carried out suggested severe adhesions, scar tissue formation, and uttering blockage. Thus, it was made clear to her that she will not be able to deliver a baby again in her life. The traditional African society places an invaluable premium on procreation and in most communities a woman's place in her matrimony is only confirmed on the positive reproductive outcome. The woman at present is in dilemma whether to leave the marriage as the husband was set to having another wife that can give him a child.
| Discussion|| |
In Nigeria, as it is often the case with most of the African countries, clinical negligence and medical errors have become a very disturbing health issues with increasing daily occurrence, especially in public health sectors. Generally, organization of health care services in Africa is a complex one, because, many African cultures have different understanding of the causes of disease which more often affect our public health system, policy, planning, and implementations. Most Africans may look for the causes of their poorly handled medical cases to their relationship between the social, natural, and spiritual environments and may not want to put the blame on the door step of the attending clinician. Most people do not just make decisions on evidence based facts regarding health, illness, death, and dying but also on cultural and religious beliefs. Attributing every medical adverse event in the course of treatment as "God's Will" and the saying "It's God's Time" for every death among most people has also become a great impediment to curbing clinical negligence in Nigerian environment.
Consequently, clinical negligence and medical errors have become the bane of medical practice with increasing daily occurrence. While litigation in healthcare system is rapidly increasing globally, which affords individual means of pursuing a perceived wrong diagnosis and treatment legally, the same cannot be said of Nigeria today. This default position has made health care providers in Nigeria indifferent to litigation in the presence of gross clinical negligence and medical errors. Though, most Nigerians may be aware of their rights to institute legal action in such situation such as, negligence with serious harm or death but the socioeconomic factors, cultural and religious complexity among other reasons within the society often makes litigation impossible for an individual. Clinical negligence and medical errors in practice is not exclusive to developing countries alone but can occur even in the most developed countries with high technology treatment options and standard of care., However, in most developed countries there are methods to put place in documenting the cases which enable the health care system checkmate the rate of occurrence through sanctioning and litigation against the offenders., The fact that some of these negligence and errors in our environment do occur, as human flaws emphasizes the need for increasing awareness and putting in place disciplinary measures among the clinicians and other health care providers as a first step in the prevention and reduction of the rate of occurrence. However, the NMDC have been working hard dealing with such issues whenever they are reported. To date, Nigeria does not have a documented data on the number of negligence and medical adverse event cases to the best of my knowledge, and this is not good for her health care system. These cases presented here illustrate some of the unidentified and unreported cases of clinical negligence and medical errors in clinical practice in Nigeria.
| Conclusion|| |
Clinical negligence and medical errors is rife in most developing countries such as Nigeria because of chain reactions of events viz.: Cultural notion regarding adverse medical events; poverty and financial ineptitude to pursue legal action against perceived negligence; ignorance the rights of the individual to seek redress in the court in the face of gross clinical negligence and serious harm; indifferent attitude of health care provider toward their patients well-being; limited options of treatment; and poor health care delivery system. It is also important to note that clinicians and health care providers in Nigeria and elsewhere are not infallible and a lot have been doing their job diligently in keeping the good reputation of the health care profession.
| Recommendations|| |
The health care stakeholders and policy makers should put in place legal and legislative measures to curb this menace while clinicians for the sake of obligation should ensure that they maintain the highest standard of patients care in their practice. Hence, there is a need to emphasize early medical ethics training for health care professional at the undergraduate level as well as promoting and organizing workshops to constantly keep them well-informed. The public from time-to-time should be encouraged to report any case of suspected negligence and medical errors in order to have documented evidence on the rate of occurrence. This in turn will help the health policy makers and medical regulatory body (NMDC) to understand the extent of the health problem and finding out the best method to reduce the rate of occurrence in the health care sector.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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