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Medical Errors – A Reality Check

19th Sri V. Venugopal Endowment Lecture

Sankara Nethralaya, true to its tradition, observed the 19th Sri. V.Venugopal Endowment lecture, paying rich tributes to one of its principal architects at the Sri VD Swami Auditorium on 29th November 2014.

The day’s proceedings started with the ceremonial lighting of the Kuthuvillaku by the family members of Sri V.Mohan Rao and the mellifluous rendition by Dr.S Meenakshi, Director – Academics.

While Dr. Shweta Agarwal, Senior Consultant, Corneal Services Department welcomed the gathering and the Chief Guest of the day, Dr Kavitha Kalaivani Natarajan, Senior Consultant, Pediatric Department paid glowing tributes to Sri. V. Venugopal, as a respected business leader of his times, and as a man who made a milestone mark being a prime pillar in the making of Sankara Nethralaya, both of whose lofty ideals synchronised to serve the community.

“Live Losier” meaning “Do no harm” – quoting the Hippocratic Oath that every Physician takes during initiation into Medical profession, Dr.N.Radhika, Senior Consultant, Corneal Services Department introduced the distinguished Chief Guest Dr Bala Ramachandran as a Pediatric Consultant & Head of the Department of Intensive Care & Emergency Medicine, Medical Director, Kanchi Kamakoti CHILDS Trust Hospital. Certified with Fellowship in Pediatric Critical Care Medicine from Children’s Medical Center, Dallas and American board of Pediatrics, USA, Dr Bala Ramachandran had special interests in Pediatric Intensive Care, General Pediatrics ,Neonatology while he passionately enjoyed photography and writing. He had to his credit several research papers, presentations and Book Chapters.

Showering encomiums on Sankara Nethralaya for its impeccable services and ideals, Dr Bala Ramachandran in his Presidential address on the critical topic – “Medical Errors – a reality in medicine today” started a torrential pour on the subject from defining medical errors to be errors in delivery of health care whether or not harm occurs, to extensively traverse on the types of errors that occurred in diagnosis, at surgery due to omission or commission, failure of medical equipments, errors due to medication that triggered adverse effect that may be preventable or non preventable.

Quoting landmark report “To err is human: Building a Safer Health System (2000)” by the Institute of Medicine and the Journal of American Medical Association, Dr Bala Ramachandran, put forth statistics that in the USA alone close to 400000 deaths last year occurred due to medical errors, most of which were preventable. While India lacked such data, medical errors were the third leading cause of death next only to Heart disease or cancer excluding accidents or crimes. He observed that Centre for Disease Control recorded 1 out of 25 hospitalised patients had Hospital acquired infections. Study by panels revealed a startling 5.2 million medical injuries reported in India.

He subtly remarked that while “Risk of harm from air travel was 1 in one million, Risk of harm from health care was 1 in 300”.

He pointed that errors occurred due to “Health care complexity, system and process design, lack of training and human factors”. In India, it was not uncommon to find over worked medical professionals or health care providers. While he admitted that human errors did occur, there was a dire need to change the conditions at work.

Encouraging participation at all levels, setting “safety standards” as administrative goal, Systematic safety processes, follow up of systems and protocols, recognising and learning from mistakes, mandatory reporting system, accountability, Incentives from Government for less error rates, continual training and professional development programs, Clinician and Pharmacists support, governmental support were few methodologies that may be put in place to prevent medical errors, he said.

After an in depth oration, Dr Bala Ramachandran keenly answered questions put forth by the enthusiastic audience.

The most interesting and absorbing day came to an end with a warm Vote of Thanks by Shri V.Govind thanking the Chief guest for his in-depth talk and Dr SS.Badrinath and Sankara Nethralaya for the continued love and high regard shown to his family members.

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