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Iatrogenic Harm

Prof B. H. Ali, Ph. D.


Department of Pharmacology
COMHS, SQU

Iatrogenic Diseases
- Iatro or iatros means Doctor
- Genic means :Caused by
- Iatrogenic diseases are doctor - created illness
- Iatrogenesis is inadvertent inattentiveadverse
effect or complications caused by medical
treatment or advice.
- Iatrogenesis can be due to other health
professionals (e.g. nurses, pharmacists etc)
- Iatrogenesis can also be due to therapy with
traditional (alternative) medicines

History of Iatrogenic Diseases


- Potential damaging effect of a healer's actions has been
recognized since ancient time.First do no harm" is an
important clause of medical ethics, & iatrogenic illness or
death caused purposefully, or by avoidable error or
negligence on the healer's part became a punishable
offence in many civilizations..
- With the development of scientific medicine in the 20th
century, iatrogenic illness or death became more easily
avoided. With the discovery of antiseptics, anesthesia,
antibiotics and new and better surgical techniques,
iatrogenic mortality decreased enormously.

History of Iatrogenic Diseases


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History of Iatrogenic Diseases


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http://www.youtube.com/watch?
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Iatrogenesis literature
- Iatrogenic disorders in modern neonatology: a focus
on safety and quality of care. Clin Perinatol. 2008; 35:1- Iatrogenic skin injury in hospitalized patients. Clin
Dermatol. 2011;29:622.
- Iatrogenic laser complications. Clin Dermat. 2011,29, 691

Glossary: General Definitions Found in Studies and


Discussions of Medical Errors

Definitions
- Adverse event: An injury or complication
caused by medical management that prolongs
hospital stay or produces lasting disability or
death (33% of AE are due to negligence )
- Ameliorative Adverse event (AAE): An injury of
which the severity or duration could ve been
reduced if different action had been taken (e.g.
sexual dysfunction lasting for several months
while taking SSRI for depression)

Iatrogenic Diseases
- The 3rd Most Fatal Disease in the USA ??
- Close to 100,000 people die every year
from plane crashes?
- 2 millions / year die due to iatrogenesis
worldwide

Possible causes of iatrogensis


-

Medical error
Side effects of treatment
Drug interactions
Negligence, faulty procedure, transfusion
unnecessary treatment for profit
Anxiety or annoyance in the physician in
relation to medical procedures / treatments
- unexamined instrument design
- Chance, illegible/ wrong prescriptions, etc

Iatrogenic Diseases include:


- Injecting wrong medication (e.g. antispectics)
- Complications after surgical procedures e.g.
hernia after a gastric bypass, Urogenital fistula
or accidental traumatic amputation of the glans
penis during ritual circumcision .
- Some are less obvious and requires detailed
investigations to identify (e.g. complex drug
interactions)

Iatrogenic Drug Interactions (DIs)


- Adverse effects can be caused by DIs e.g.
when a Dr. or pharmacist fail to check for all
drugs a patient is taking & prescribe new
ones that interact agonistically or
antagonistically [THINK OF EXAMPLES!]

Iatrogenic disease (I. D.) in the elderly


- For prevention of I.D, identify patients at
high risk
- Risk factors of I.D. in the elderly include:
- 1. Drug induced I.D.
- 2. Multiple chronic diseases
- 3. Multiple physicians
- 4. Hospitalization
- 5. Medical or surgical procedures

Medical Errors (ME)


- Doctors should consider the best interests of their
patients and 'do no harm'.
- Preventable adverse effect of care, whether or not it
is evident or harmful to the patient, including an
inaccurate or incomplete diagnosis or treatment of a
disease, injury, syndrome, behavior, infection, or
other ailment.
- ME can be individual human error, but are often
systems - based and in many cases are avoidable.
- Reporting and learning from ME improves the
safety of patients.

MEs vs AEs
- Must differentiate between MEs & adverse events
(AEs).
- Most MEs are not AEs (they do not harm patients) &
most AEs are not MEs & are therefore not
preventable.
- AE: An injury or complication caused by medical
management that prolongs hospital stay or
produces lasting disability or death.
- ME: Any act that will, based on currently
available information, substantially increases
the risk for an adverse event.

Ethical Rationale for Error


Disclosure to patients
- Informed Consent: Error disclosure is a form of
informed consent, conveying important information to
patients that they need to make informed decisions
about their subsequent medical care.
- Truth-Telling: Important to disclose errors as a form of
truth telling. Errors should be disclosed even if the
information is not essential to informed decision-making.
- Justice and Fairness: Justice also support error
disclosure, as such information is often a prerequisite to
a patient accessing compensation for their injuries.

Issues related to medical errors


- Many Drs. worry that disclosing errors to patients will
precipitate lawsuits. Actually patients are more likely to
sue Drs. when communication breaks down, fear of
malpractice suits will be a significant barrier for open
discussion about errors with patients.
- Drs. can get mixed messages from different sources who
explicitly say Drs. should not apologize to patients as an
apology is an admission of fault. How to handle
apologies effectively is a key issue for error disclosure.
-

What patients should find in


an error disclosure
- Explicit statement than an error occurred
- What the error was & its clinical
implication
- Why the error happened
- How recurrence will be prevented
- An apology

Iatrogenesis due to misdiagnosis


- Misdiagnosis can lead to iatrogenesis, e.g.
diagnosis with a false psychological or psychiatric
condition (e.g. bipolar disorders).
- Iatrogenic factors in chronic pain patients include
over-investigation, inappropriate information and
advice given to patients as well as misdiagnosis,
over-treatment, and inappropriate prescription of
medications.
- Substance abuse comorbidities can produce
symptoms similar to other psychiatric disorders,
leading to misdiagnosis.

Nosocomial Infections (NIs)


- NI is an Iatrogenic infection that is acquired in
hospital & was not present or incubating on
admission.
- NIs can be caused by unclean or inadequately
sterilized needles, surgical instruments and
ungloved hands to perform medical or dental
procedures e.g., IV catheter or hepatitis B or C
infection can be transmitted by dentists or
surgeons.

Pharmcogentics & iatrogenic disease


- Pharmacogentics studies differences in the metabolic
pathways that affect individual responses to drugs, both
in terms of therapeutic effect as well as adverse effects.
- There are many examples and some present as medical
emergencies. Examples of pharmacogentic dosorders:
- 1. Malignant hyperpyrexia (halothane)
- 2. G6PD deficiency (hemolytic anemia & antimalarials)
- 3. Lactic acidosis (metformin)
- 4. Hepatic adenoma (oral contraceptives)
- 5. Bradycardia (beta blockers e.g. metoprolol) -

Prevention of Medical Errors


-

These help prevent errors:


A) Effective reporting system
B) Analysis of these reported events
C) Improved system of care
D) Learning from the SAFETY SCIENCES
(including Human Factors Engineering)
- E) Technology, including information technology,
physician order entry, design of medical devices etc
- F) Need for EVIDENCE on what works to prevent
errors

Potential Strategies for Coping With


Medical Mistakes

1. Problem focused
2. Emotion -focused

Problem focused Strategies


- Acceptance of responsibility
- Consultation to understand
nature of mistake
- Consultation to correct
mistake
- Planned problem-solving
- (e.g. obtaining extra training)

Emotion focused Strategies


-

Pursuance of social support


Disclosure to colleague, friend or spouse
Disclosure to patient
Emotional self-control (e.g. repressing
ones emotional response)
- Escape avoidance
- Distancing
- Reframing of mistake (e.g. recognizing it as
inherent in practicing medicine).

Common Changes in practice


following mistakes
- A) Constructive Changes
- B) Defensive Changes

Constructive Changes in practice


following mistakes (1)
-

Increasing vigilance:
a) paying more attention to details
b) confirming data personally
c) changing data organization
d) ordering additional tests as
appropriate
- e) improving screening for disease
- f )Improving communication with patients

Constructive Changes in practice


following mistakes (2)
- Increasing information seeking by ASKING
ADVICE and by READING.
- Improving self-pacing
- Improving communication with staff
- Supervising others more closely

Defensive Changes in
practice following mistakes
- Being unwilling to discuss error
- Avoiding patients with similar problems
- Ordering additional but unnecessary tests

Adverse effects associated with vaccines


- Vaccines are associated with unwanted effects (no effects
to severe brain damage).
- In the past these adverse effects were due to product
defects.
- Vaccines are generally safe, but can cause some
problems in a few individuals receiving them.
- Doctors are often accused of downplaying the risks of
vaccination & claiming that childhood immunization is
completely safe and that there is no reason to worry
when children get immunized.
- These concerns should be discussed as denying or
dismissing them may lead parents and patients to seek
advice from uninformed sources.

Thalidomide disaster, 1961


Thalidomide was described as a sedative with minor side
effects in 1956.
- It was used as antiemetic and anxiolytic in pregnant
women.
- Only 2 years after thalidomide's launch as Contergan in
Germany, it's alleged lack of toxicity came into question,
with reports of the drug causing numerous side effects.
Shortly thereafter, thalidomide was connected with an
epidemic of deformities (limb truncations and
microphthalmia.) in children whose mothers had taken
the drug during pregnancy.
- Thalidomide's teratogenic effects led to the institution or
strengthening of some regulatory bodies in UK & USA.

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