VOLUME 2 NUMBER 1 & 2 2009
M DICAt
UNIVERSITY OF IBADAN LIBRARY
INTERNATIONAL JOURNAL OF DEVELOPMENT
IN MEDICAL SCIENCES
VOLUME 2 NUMBER 1 & 2 2009
EDITORIAL BOARD
EDITORS
Ekan E. Etim, Ph.D Prof. Maria O. Nwosu
University of Uyo University of Nigeria 
Uyo, Nigeria Nsukka, Nigeria
CONSULTING EDITORS
Prof. E. N. Aniebona Nweze N. 0., Ph.D
Novena University Nuiversity of Nigeria 
Ogume-Kwale, Nigeria Nsukka, Nigeria
Isaac Kwame Dontwi, Ph.D Prof. Bede Ibe
Kwame Nkrumah Univ. of Tech. University of Nigeria 
Kumasi, Ghana Teaching Hospital 
Ituku-Ozalla, Nigeria
Prof. Patrick Manu Prof. Samson Mashele
Bugema University Central Univ. of Tech. 
Kampala, Uganda Free State, South Africa
AIMS AND SCOPE
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UNIVERSITY OF IBADAN LIBRARY
UNIVERSITY OF IBADAN LIBRARY
INTERNATIONAL JOURNAL OF DEVELOPMENT IN
MEDICAL SCIENCES
Volume 2 Number 1 <& 2 2009
CONTENTS
Diagnosing Skin Diseases Using an Artificial Neural Network 1
Ledisi Giok Kabari 
Olumide Owolabi
Isolation of Antibiotic Resistant Staphylococcus Aureus Strains 
from Nurses at Umaru Sanda Ndayeko General Hospital, 11
Bida, Niger State 
Gana, ].
Abel, G. J.
Umar, A. N.
Danazumi, N.
An Assessment of Service Delivery in Primary Health Care 
Centres in Rural Areas: A Study of Osun State, Nigeria 19
Adebimpe, W. Olalekan 
Bamidele, J. Olusegun 
Dairo, M, David
Intestinal Parasites of Dogs Slaughtered for Consumption in 
Nigeria: A Study of Fwagul and Kuru, Jos South Local 27
Government Area, Plateau State, Nigeria 
Kaze, P. D.
Dayok, O.
Silas, P. M.
Preliminary Study of the Medicinal Property of Khaya Senegalensis 
(Savannah Mahogany) Seed Oil and the Formulation of Anti Fungal 36
Hair Cream For Commercialization 
Uzoh, R. D.
Agho, M. O.
Ibok, N. U.
Uko, J. P.
The Role of Traditional Medicine in Primary Health Care Delivery 46
Nwinadum Gbenenee
III
UNIVERSITY OF IBADAN LIBRARY
“Who Is The Victim?”- The Effect of Medical Error on Physicians 
and Patients 57
Jadesola O. Lokulo-sodipe
The Antimicrobial Broad Spectrum Efficacy of Khaya Senegalensis 
(African Mahogany) 68
Gana, Jerry 
Manga, S. B.
Mohammed, A. K.
Determinants of Utilization of Internet Resources by Family 
Physicians in Nigeria 78
Shabi, I. N.
Shabi, O. M.
Health Problems Associated with Garri Production in Rural 
Communities of Southern Nigeria 89
Winadum Gbenenee
The Role of Science and Technology in HIV/AIDs Pandemic 97
Obuh, R. E.
Ikpeseni, S.
Spectrophotometric Study on Humic Material Substances Present 
in Some Drinking Waters in Northern Nigeria 105
Ebe, N. Udoka
IV
UNIVERSITY OF IBADAN LIBRARY
"WHO IS THE VICTIM?" - THE EFFECT OF MEDICAL 
ERROR ON PHYSICIANS AND PATIENTS
Jadesola O. Lokulo-Sodipe
A bstract
Medical error is an adverse event that could be prevented, given 
the current state o f medical knowledge. It has been defined as 
the failure o f a planned action to be completed as intended or 
the use o f a wrong plan to achieve an aim. Medical errors can 
occur in any health care setting in the form  o f an ‘adverse drug 
event, improper transfusion, surgical injuries and wrong site 
injuries, suicide, restraint-related injury or death, falls, burn, 
pressure ulcers and mistaken patient identity, When errors occur, 
ethics, professional policy and the law suggest that timely and 
candid disclosure be the standard practice. Disclosure however 
raises a number o f ethical, legal, and psychological issues which 
will be discussed in this study. The study further examines the 
philosophical basis fo r  disclosure and non-disclosure; the duty 
owed by the physician to the patient; the effect o f disclosure on 
patients and physicians. In discussing the effect o f medical error 
on patients and physicians, the benefit and harm o f disclosure 
and its effect on patient/physician relationship will be examined.
Key w ords: Medical Errors, Effect, Disclosure, Patient/ 
Physician Relationship.
INTRODUCTION
To err, they say is human. Even the smartest and m ost caring o f  hum ans make 
errors. In clinical medicine sometimes, errors result in serious patient harm. The subject 
o f  medical error is however not a new one. Medical error is an adverse event that could 
be prevented1 given the current state o f  medical knowledge Brennan, 1999. It has been 
defined as “the failure o f  a planned action to be com pleted as intended or the use o f  a 
wrong plan to achieve an aim ” IOM, 1999.
JADESOLA O. LOKULO-SODIPE is a Lecturer in the Faculty o f Law, University o f Ibadan, 
Ibadan, Nigeria.
International Journal of Development in Medical Sciences Vol. 2, No. 1 & 2 
© 2009 by The Development Universal Consortia. All Rights Reserved.
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Medical errors can occur in any health care setting in the form o f  an ‘adverse drug event, 
improper transfusion, surgical injuries and wrong site injuries, suicide, restraint-related 
injury or death, falls, bum , pressure ulcers and mistaken patient identity. It is, however, 
more likely to develop in an emergency department, an intensive care unit or an operating 
room.
W hen errors occur, ethics, professional policy and the law suggest that timely 
and candid disclosure be the standard practice. Studies have shown that patients expect 
disclosure o f  errors (G allagher et al, 2009). D isclosure how ever raises a num ber o f  
ethical, legal, and psychological issues which will be discussed in this study. The study 
further examines the philosophical basis for disclosure and non-disclosure; the duty owed 
by the physician to the patient; the effect o f  disclosure on patients and physicians. In 
discussing the effect o f  medical error on patients and physicians, I will look at the benefit 
and harm o f  disclosure and its effect on patient/physician relationship.
Medical Errors- The Need For Disclosure
Everyone makes mistakes. Human fallibility can be moderated, but it cannot be 
elim inated. In the sam e vein, adverse events and m edical errors are not uncom m on. 
M edical errors as noted earlier are considered to be “preventable adverse m edical 
events” Brennan, 1999. Patients are harmed as a consequence o f  either what is done to 
them - errors o f  comm ission; or what is not done but should have been done to prevent 
adverse outcom e- errors o f  om ission. Unlike honest m istakes, negligent actions are 
preventable, harmful errors that fall below the standard expected o f  a reasonably careful 
and knowledgeable practitioner acting in a similar situation.
It has been argued that not all errors are truly preventable G aw ande, 2002. 
Gawande noted that ‘no matter what measures are taken, medicine will sometimes falter, 
and it isn’t reasonable to ask that it achieve perfection. W hat is reasonable is to ask that 
medicine never cease to aim  for it’ (Gallagher et al. , 2009).
However, there is no place for m istakes in m odem  m edicine (M edical Error, 
2003). Society has entrusted physicians with the burden o f  understanding and dealing 
with illness.
Developments in medical technology, the apparent precision o f  laboratory tests, 
and innovations that present tangible images o f  illness have created an expectation o f 
perfection. M edical errors do occur, although they are not admitted publicly and very 
often are swept under the carpet.
Before the 1990s, “perfect perform ance was expected and was felt to be 
achievable through education, professionalism, vigilance and care (ISMR, 2006). This 
led to fear o f  retribution, ranging from undue embarrassment, employment and/or licence 
termination and drove errors underground.
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The m id 1990s however, brought about a change; health care providers were 
starting to acknowledge human fallibility and the impossible task o f  perfect performance. 
M edical errors were starting to be seen as the result o f  mental slips or lapses or honest 
m istakes that were rooted in system, process, technical, or environm ental weaknesses 
that lay dormant in the organization until errors or proactive assessment efforts brought 
them  to light (ISM PR, 2006). M istakes m ade in the care o f  patients, especially in the 
hospital settings, have draw n a great deal o f  attention since the 2000 R eport o f  the 
Institute o f  M edicine (IOM).
According to that report, as many as 98,000 people die every year in the United 
States o f  America because o f mistakes by medical professionals in hospitals. The IOM 
Report noted that more people die annually from errors than from motor vehicle accidents, 
breast cancer or AIDS -  3 causes o f  death that receive far more public attention (To Err 
is Human, 2000). Medical errors can be categorised into two, namely; (a) system errors 
which are derived primarily from flaws inherent in the system o f medical practice. In this 
instance, the physician shares responsibility with other elements o f  the health care delivery 
system, and (b) individual errors arise from deficiencies in the physician’s own knowledge, 
skill or attentiveness. In tills, for instance, the physician has the primary responsibility.
Examples o f  medical error include transfusion o f HIV infected blood, mis-match 
o fb lood at transfusion, leaving foreign bodies like sponge or instrument in surgical wounds; 
extravasations o f drugs into necrosis; forgetting a tourniquet in the upper arm resulting in 
arm gangrene and amputation, and medication errors. The causes o f medical errors are 
com plex. Som e causes are; com m unication error; the increasing specialization and 
fragm entation o f  health  care; hum an errors resulting from  overw ork and burnout; 
manufacturing errors; equipment failure; diagnostic errors and poorly designed buildings 
and facilities.
The occurrence o f  a m edical error has a ripple o f  effects. The error can affect 
the fam ily o f  the patient, friends and even the co-workers. The patient faces a lack o f 
productivity, loss o f  quality o f  life, depression, traumatisation and increase in fear o f  an 
error re-occurring in the future. A  health care provider goes through the same issues 
after an error and equally powerful emotions are felt. According to Gallagher (2009). 
“physicians felt upset and guilty about hanning the patient, disappointed about failing to 
practice medicine to their own high standards, fearful about possible lawsuit, and anxious 
about the error’s repercussions regarding their reputation” (Gallagher, 2003).
W hen errors occur, disclosure, apology and restitution are expected. W hen 
medical errors occur, physicians should take the lead in disclosing error to patients and 
their fam ilies (H erbert, 2009). Full disclosure to the patient is the ethically and 
professionally responsible course o f  action. Disclosure o f  enor is consistent with ethical 
advances in medicine toward more openness with patients and the involvement o f patients
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in their care (Herbert, 1996), advances on informed consent and truth telling (Etchells 
et al., 1999). D isclosure is vital for the im provem ent o f  patient safety and quality o f 
care. By not disclosing adverse events, the physician fails the patient in terms o f  honesty, 
openness and respect. Furthermore, nondisclosure may put the patient at risk for future 
harms because he or she does not know what happened. Disclosure provides the patient 
with potentially vital information for m aking future health care choices and decisions. 
D isclosure is also expedient out o f  respect for patients as persons. Thus, they have a 
right to know  about critical incidents even if  they are not physically harm ed by them. 
Furtherm ore, by the principle o f  justice or fairness, patients w hen harm ed, should be 
able to seek appropriate restitution or recompense. This ethical rationale for disclosure, 
based on a strong notion o f  autonom y, goes beyond w hat the law  m ight require one 
to do.
On the other hand, failing to disclose errors to patients underm ines public trust 
in medicine because it potentially involves deception and suggests preservation o f  narrow 
professional interests over the well-being o f  patients. This failure can be seen as a breach 
o f  professional ethics (a lapse in  the com m itm ent to act solely for the patien t’s best 
interests).
Similarly, patients may be cause avoidable harm if  they are injured further by the 
failure to disclose. N on disclosure o f  error may undermine efforts to improve the safety 
o f  m edical practice i f  the error is not reported to the appropriate authorities. W hen 
practitioners w itness errors m ade by other health care providers, they have an ethical 
and legal obligation to act on that information.
Disclosing errors can be challenging for practitioners (Hilfiker, 1984). Medical 
professionals have high expectancy o f themselves; therefore, they find it difficult to admit 
errors openly (Finkel stein et al., 1997). The physician should however, be the one to 
reveal the error. It is not proper for the patient to take the lead in disclosure. The patient 
and family m ust be informed in an objective way and m ust be perm itted to express any 
concerns that they m ay have. A n open or transparent approach w ill help strengthen, 
rather than w eaken the doctor-patient relationship (H erbert et al., 2009). W here the 
adverse effect requires medical attention, doctors ought to disclose and offer help. It is 
reassuring to patients to know  that their doctor is also trying to set the harm  right by a 
clearly defined course o f  action. All relevant inform ation regarding the sequence o f  
events leading to the adverse outcom e is presented as clearly as possible. Disclosure 
should, take place at the right time, when the patient is medically stable enough to absorb 
the information, and in the right setting (Kalantri, 2003).
Disclosing medical errors to patients is a long way from  being the norm. There 
are certain barriers to disclosure. These include physician embarrassment, personal anxiety, 
and legal concerns. The physician faces the possibility  o f  a legal action, m ore so in 
a society where m edical errors are classified as a tort which could result in punishment
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and financial devastation. There is a significant conflict between ethical considerations 
and se lf  preservation (Constantine et al„ 2009).
Arguments have been put forward for disclosure and non disclosure o f  medical 
errors. I go on  now  to discuss the philosophical basis for both argum ents. A ristotle’s 
N ichom achean Ethics (Aristotle, 1954) were based on the m oral virtues o f  courage, 
temperance, prudence and justice. Moral virtue is the habit o f  choosing the golden mean 
betw een extrem es as it relates to an action or an em otion. It is the learned ethical 
choice, through teaching and experience that has evolved into a conditioned response to 
do the right thing in different circumstances.
The m oral virtues o f  courage, tem perance, and prudence generally pertain 
to one’s control o f  inner em otions and thoughts as well as reacting to environm ental 
situations. Justice, however, involves two or m ore hum ans w hose interests m ust be 
considered, according to societal m ores and laws, if  there is to be a ju s t outcom e. By 
Aristotle’s argument, the physician and the patient entered into an agreement, based on 
the moral virtue o f  justice. The physician would treat the patient in the same m anner that 
he w ould w ant to be treated had he been the patient. Consequently, the physician is 
duty bound to disclose the truth in all aspects o f  care to the patient.
Plato on his part suggested that lying in certain circum stances is not immoral 
(Plato, 1937). Furthermore, according to Plato, intentional deception when done in the 
patient’s best interests is considered by him to be morally justified. The fundamental 
issue is “w hen done in the patient’s interests”, and who will decide w hat is best for the 
patient. Plato’s sense o f  personal and societal moral virtue would support the idea that 
full disclosure between hum ans who are involved in a solemn trust is expected.
On the other hand, he has considered that the physician has responsibilities to 
his patient and could be expected to m ake m oral judgem ents on w hat is best for the 
individual in question. It would be consistent with Plato’s philosophy for a physician to 
intentionally deceive a patient w ith inoperable lung cancer in order to m ake his last 
m om ents on earth tolerable. One can distinguish this scenario with that o f  the patient 
involved in m edical error. The latter has an active agreement w ith his physician. This 
gives rise to a trust situation between the two. This in turn demands open communication. 
The physician’s deception in this instance would be to protect him  from litigation and 
does no service to the patient. In the former situation, the relationship is betw een the 
cancer patient and the disease. The physician is acting as an interpreter o f  the situation. 
The physician is gaining nothing from the deception.
K ant’s moral theory (Kant, 1996) is considered to be the foundation o f  m odem  
bioethics (Bernstein & Brown, 2004). His theory is based on the autonom y and dignity 
o f  the individual. According to Kant, morality can exist only by virtue o f  our autonomy 
as rational beings. The moral worth o f  an action is not related to the beneficial outcome 
but whether it is done from a sense o f  duty or obligation. Kant’s moral law or categorical
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im perative states that every act has to stand on its m oral virtue and be judged  as if  it 
were to becom e a universal law o f  nature. For Kant, there is no reason to lie because to 
do so violates the principle o f  the ‘categorical imperative’.
Consequently, under K ant’s moral theory, the physician has no option but full 
disclosure o f  his error to the patient. By lying, he violates the categorical im perative 
against lying and deprives the patient o f  his moral dignity as hum an being. Similarly, by 
seeking to protect himself, he also violates the principle o f humanity in one’s own person 
as well as in the person o f  any other, never m erely as a m eans, but as the same tim e as 
an end.
Utilitarianism  based it moral theory on the ‘utility’ or outcom e o f  an act rather 
than its motive. To act m orally was to act in such a way that the am ount o f  benefit or 
pleasure achieved was maxim ized and the harm or ‘gain’ m inimized the greatest good 
for the greatest number. M ill, used B entham ’s theory o f  utility to em phasise that the 
quality o f  the good achieved mattered. According to Mill, the good, broadly construed, 
was not just the good o f  the individual, but the good o f  society as a whole.
Furtherm ore, in his principle o f  equality, every person m ust be considered to 
count for one and only one. According to the utilitarian, what ultimately gave happiness 
w as the sense that one was a good person w ho acted according to his conscience in 
treating others well. In this instance, the patient, though he will be upset, will benefit by 
having accurate medical information upon which he can base his further treatment decisions 
and choice o f  doctor. O ther patients w ill also benefit as disclosure o f  his error may 
force the physician to exam ine the system  in w hich he w orks and to  m ake changes 
which will help prevent errors in the future.
In the utilitarian framework the medical profession as a whole is also served by 
the openness; to confess error and apologise is a courageous and honourable act that 
reflects well on the profession and serves to increase public confidence in its integrity 
(Constantine et al., 2009).
From the foregoing, when errors occur, the physician should disclose the entire 
incidence as it occurred in a straight forw ard m anner, show ing that it w as indeed a 
mistake. He is obliged to give the best explanation as possible, in a way the patient and 
family will understand and should say the steps he/she intends to take to prevent future 
occurrence and apologise. In my opinion, the Kantian theoiy best supports full disclosure 
o f  medical errors. Aphysician must respect the patient’s dignity and act with beneficience, 
sympathy, and conscience and without arrogance. He is under an obligation to place the 
patient’s interest and his profession above his own.
There is however another side to this argument and that is that these philosophical 
theories do not provide adequate guidance for the 21 st centuiy physician. This argument 
is based on the notion that, m odem  day practice o f  m edicine has evolved to the point 
that only perfection is acceptable. Nowadays, errors are viewed as being the result o f
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negligence as opposed to honest mistakes. Consequently, disclosing medical errors to 
patients will only lead to a never-ending series o f  litigation w hich in turn could lead to 
bankruptcy o f  a num ber o f  health care facilities.
The consequentialism  theory, determines whether an act is morally right based 
on the net results o f  that action- does the good outweigh the bad? Consequentialism  
suggests that one ought to do that act which realizes the best overall net consequences 
when one considers both the harm and the benefit to all those involved.
With regard to disclosure o f  medical errors, one m ust consider the harm and the 
benefit to the patient and his family. It also appropriate, to consider the harm  and 
potential benefit to the physician. The decision made with regards to disclosure, should 
be the best one with regard to the overall net consequences to both the patient and his as 
well as to the physician. Consequently, reasons to disclose medical errors would include 
any significant benefit to the patient and his family as well as any benefit to the doctor 
that comes secondary to disclosure. Reasons not to disclose w ould be those that cause 
patient or family harm as well as harm to the physician.
W hile admitting that disclosure carries potential benefits to both the patient and 
the physician, it also carries potential harm to both parties. The potential benefit to the 
patient is the opportunity o f  fair compensation through litigation. To the physicians, it is 
the strengthening o f  physician/patient relationship.
In general, acknowledging mistakes could potentially harm  patients in a  couple 
o f  ways. Firstly, it can inhibit patient/doctor relationships or patient family relationships. 
Secondly, it could incite greater anger or emotional distress in a  patient w ho has been 
harm ed or in the family o f  a patient who has been harmed.
Physician harm m ust also be considered in consequentialism when considering 
reasons not to disclose. The doctor could be harm ed by inducing anxiety and severe 
emotional distress during and after disclosure. In addition, the physician runs the risk o f 
losing respect, patient referrals, hospital privileges and contracts. There is therefore, a 
significant potential econom ic loss. There is also an exposure to physical attack from 
the patient and family.
W hen utilising the c o n s e q u e n tia l  approach therefore, it would appear that the 
only reason for disclosure is to  allow  for ‘appropriate’ com pensation for the patient. 
However, in a society like ours, appropriate com pensation for the patient will alm ost 
impossible, considering the challenges o f  litigation in Nigeria. Potential reasons not to 
disclosure would include creating emotional distress and physical attack for the physician.
The option o f  non disclosure is more attractive where the patient is dead. This 
is because, disclosure in that instance does not help the patient -  it cannot bring him/her 
back to life. From an emotional stand point, disclosure will not impact positively on the 
grief o f t he family neither will the physician find a great deal o f consolation following an 
act o f  contrition. Here the patient/doctor relationship has ceased to exist as the patient 
is dead.
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CONCLUSION AND RECOMMENDATIONS
By combining Aristotelian teleological and Kantian deontological approaches, 
we can conclude that full disclosure o f  medical error to the patient and patient’s family is 
the best option. However, if  we apply the consequentialist approach, after weighing the 
benefit and harm that will occur to both the patient and the physician, we would arrive at 
the opposite conclusion.
Professional codes enjoin physicians, w hile caring for patients, to regard 
responsibility  to the patient as param ount. Be that as it may, the physician is also 
responsible to his family, hospital, colleagues and wider community. He is not expected 
to place him self in a position whereby his ability to continue to care for current and future 
patients is jeopardised or his personal life is endangered.
Disclosure o f  medical errors can be beneficial to both the physician- maintaining 
a virtuous character, which in turn leads to trust and a good patient/doctor relationship 
and to a patient- the power to exercise the right o f  self determination, which can be done 
only w ith the accurate know ledge o f  the relevant details o f  treatm ent. Conversely, 
significant harm  m ay com e to the physician if  he fully discloses errors to the patient 
through litigation, jungle justice, physical attacks etc, which may im pede his ability to 
continue providing professional services. In deciding to disclose, the physician needs an 
accurate m easurem ent o f  the probability that disclosure o f  an error will seriously harm 
him and his other patients.
In a study (G allagher et al., 2007) carried out on the attitude o f  patients and 
physicians to disclosure o f  medical errors, it was found that both patients and physicians 
had unmet needs following errors. According to the study, patients wanted disclosure o f 
all harmful errors and sought information about what happened, why the error happened, 
how  the error’s consequences will be mitigated, and how  recurrence will be prevented. 
Physicians on their part, agreed that harm ful errors should be disclosed but ‘choose 
their words carefully’ when telling patients about errors. Physicians however, worried 
that an apology m ight create legal liability. The study showed that physicians were also 
upset w hen errors occur but were unsure o f  where to seek em otional support.
M edical errors are an unfortunate but inescapable part o f  medical practice. It is 
therefore necessary to derive a mechanism for dealing with them  when they occur. Full 
disclosure is vital for im provem ent o f  patient’s safety and quality o f  care. I am  o f  the 
opinion that i f  we adopt a  system  o f  blam e free reporting o f  avoidable, no t culpable 
m istakes, disclosure w ill be the order o f  the day. Steps should also be taken to make 
provisions for caring for the emotional outcome o f  these errors for both the patient and 
physicians.
Offering an apology with disclosure is an important com ponent o f  addressing 
m edical errors. A n apology would include an acknowledgem ent o f  the event and
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one’s role in the event, as well as a genuine expression o f  regret for the patien t’s 
predicam ent. A n apology can have profound healing effects for all parties. For the 
physician, an apology can help diminish feelings o f guilt and shame. For the patient it can 
facilitate forgiveness and provide the basis for reconciliation (Lazare, 2006). Patient’s 
safety and physician w elfare will be well served i f  the latter can be m ore open and 
honest about mistakes to their patients, colleagues and themselves.
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