Brief introduction of details of a case
Patient Li Mou with " two lower limbs are lack of power, accept differs half moon beyond to accentuate and bellyacke 1 day " join the 3 divisions inside prefectural hospital for action in chief. Be on duty assistant doctor armour is examined, be on duty after division director second dealt with formalities of be in hospital for the patient, by electrolyte disorder, gastritis is opposite disease infusion cure. In the morning 8 when third of this family doctor is on duty, be in charge of continueing to treat, the examination such as hematic convention, cardiogram had in treating a process, add used antiphlogistic drug. Afternoon 13 when when be defeated by adipose breast 30 minutes or so, the patient appears suddenly breath is difficult, rescue of classics doctor third is invalid die. To the patient when hospital of the world midday death undertook discussion, thinking is a head likely burst of interlining of sudden death of sex of source of embolism of dry block, lung, heart, aorta bleeds and sudden death.
Center of appraisal of the judicatory in lawsuit passes to controversy of anamnesis material authenticity with both sides big, and did not undertake autopsy, cannot make clear cause of death, admit to have bigger effect surely to this case fault for, do not grant to accept.
Court of first instance thinks, the hospital puts in the following problem in process of diagnosis and treatment: (1) because when patient death occurs medical treatment controversy, both sides fails to seal up for keeping in time below bilateral and present condition according to the regulation anamnesis; (2) be admitted to hospital anamnesis of home page of licence, ill case, outpatient service, illness informs a book to write violate anamnesis to edit a standard, especially patient family member has the illness of major exception to inform a book is two people handwriting, one person signs, and handwriting of share of venture of medical treatment measure, medical treatment is illegible, the ordinary person identifies hard, the public health worker that should treat a hospital fails to be used up completely tell demonstrative obligation. (3) edit a standard according to anamnesis of be in hospital, hospital medical records is short of break hand over a record, just think because of sufferring from the hospital is on duty all the time the make a diagnosis and give treatment that division director second never participates in pair of patients, and according to be on duty division director second and doctor third are stated is doctor third in the morning 8 when make carry on be treated to the patient, should regard anamnesis as not complete. Integrated above element, illative hospital treats fault of the existence in the activity in this, drink the responsibility that decides a hospital to assume 70 ％ .
The hospital refuses to obey put forward to appeal, 2 careful court rejects appeal, maintain original judgement.
Law brief analyse
One, because anamnesis is written,beware non-standard and load duty
" tort liability law " fiftieth 8 regulations: "The patient has damage, because of one of following scenario, illative medical establishment has fault: (one) lawbreaking, administrative regulations, regulations and the regulation with other concerned normative diagnosis and treatment; (2) hide or reject to provide the anamnesis data that concerns with dispute; (3) forge, distort or data of anamnesis of destroy by melting or burning. " liability issue case is damaged in medical treatment in, a lot of patients are met pair of as a result of square to cure distrust anamnesis demur, ask the court sets the fault of illative hospital according to this, the law that occupy cure assembles a group " countrywide medical treatment damaged big datagram of liability issue case to accuse 2018 " show, in trying practice, just forge to cure, distort the cognizance rate of anamnesis is only 13% , the scale of cognizance anamnesis flaw is 21% , the scale that cure just loses a lawsuit because of anamnesis problem is 11% .
Anamnesis material is the most crucial evidence in medical treatment dispute, however anamnesis is written illegible common phenomenon already was in medical establishment, pair of this phenomena often also appear on the network " spit groove " , but the attention that fails to cause numerous medical establishment all the time. The medical establishment in this case is written because of anamnesis just about non-standard and load duty. Anamnesis is written illegible, can maintain to the responsibility of medical establishment on one hand influential, for instance this case just informs a book in the illness because of cure handwriting of share of venture of medium medical treatment measure, medical treatment is illegible, the ordinary person identifies hard, be failed finally to be used up completely by forensic cognizance public health worker tell demonstrative obligation, bear adverse consequence; On the other hand according to " precaution of medical treatment dispute and processing byelaw " responsibility personnel may be given fine related the 47th regulation, demote dismiss, order halt hold the administrative punishment such as course of study.
2, shift changing rule spends fulfil should reach the designated position
National Wei Jian appoint safety of released medical treatment quality set in core system point " be on duty to be spent with shift changing rule " , the requirement is worth activities of all diagnosis and treatment between schedule to must note case history in time, hand over class content ought to only book record, sign jointly by personnel of hand over to the next shift and carry on personnel affirm. What the end that shift changing rule spends depends on ensuring process of patient diagnosis and treatment is successional, it is medical establishment each section office ought to father the system at fulfilling. " hospital duty is spent " in spend to shift changing rule in each section office fulfill a standard to all make particular demand, be in for example thirtieth 8 " delivery room duty is spent " in regulation " strict shift changing rule is spent, carry on person should measure blood pressure, heart audition an embryo, make a record " ; Thirtieth 9 " infantile room duty is spent " in regulation " outside handing over a class to divide written report every time, want perambulatory new life chase one verbal hand over to the next shift. Sick into death new student hand over to the next shift this getting on it is clear to should be written, write down special illness nurse on record sheet. All things should arrange all ready to give next " . Nursing respect, " the polyclinic classifications nurse rudder (try out) " in thirteenth regulation: "Right fancy nurse of the patient nurse include the following point: ... (6) the class joins by executive bed... " the medical establishment in this case did not ask to fulfill shift changing rule to spend according to legal laws and regulations, had done not in time hand over a record, because anamnesis is short of,carry finally duty, what ought to cause medical establishment is alert.
3, epilogue
The ancients cloud, practise medicine " if face abyss, on thin ice " , medical personnel is in the job a bit one carelessness, send a person likely to disable, endanger life even. Will tell to the controller of medical establishment, want to go to infiltration of law law plan inside the courtyard in regulations system, establish effective supervisory mechanism, avoid the generation with contradictory doctors and patients from hospital administration level, become risk of law of good medical treatment at the same time be on guard.
Toward period wonderful reviewing
? Cure patient contracts third liver virus, who comes to the rights and interests that cure protects personnel protection? | Cure law is collected
? "Does the net make an appointment with a nurse " rely on chart? See Internet together + nurse the legal problem of backside
? Disagree to appraisal opinion? Besides application new appraisal, you are OK still so do
Thought of doctors and patients fors the time being, collect with respect to law seeking medical service " link "
