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Dr. S. Terrence G. R. De Silva, (MBBS, DPS, DFM, DLSHTM, M.Sc. (Lond), MD) Deputy Director General (Medical Services) I (Former Director of the National Hospital of Sri Lanka, Colombo)

2009 2

Copyright 2009 Ministry of Healthcare & Nutrition, Sri Lanka Published by Medical Services Division



You and Your Patients 08 Principals governing provision of medical care .. 21

ISBN 000-000-0000-00-0

Eight points concept to enhance positive attitudes towards patients 22 Avoiding Medical Errors 28 A message from Blood Bank .. 40 Communication skills for Doctors .. 50 Guidance in issuing medical certificates . 56

Contributors: Dr. S. Terrence G. R. De Silva Dr. Lakshman Senanayaka Dr. Deepthi Samarage .. (Blood Bank)

Message from the Hon. Minister of Healthcare and Nutrition At the outset let me congratulate you for selecting a noble profession as your vocation and successfully completing your university degree. You are about to start the mandatory training period which would give you the necessary experience and skill which is a prerequisite to heal the sick with responsibility. Sri Lanka is proud of its achievements in the field of health care, which is amply substantiated by our health indicators which are comparable to those in the developed world. One of the important factors that contributed to this success story is the commitment and dedication of all the health care workers functioning at different levels in the Ministry of Health and peripheral institutions. I am happy that the majority of our staff working towards providing Quality Health Care to all Sri Lankan without any discrimination. Brief but valuable information in this booklet would guide you to be a worthy professional to whom the Sri Lankan public could truly be grateful for.

Message from the Secretary, Ministry of Healthcare and Nutrition I wish to welcome you to the Ministry of Healthcare and Nutrition. I am very happy that the Ministry of Health was able to provide you with this opportunity of training as a medical intern to improve your knowledge and also gain the necessary understanding and skills to treat the sick. It is indeed a challenge to be able to fulfill the ever increasing expectations of the public who seek care, within a rapidly enlarging horizon of technological improvements and access to information. You as a House officer would be playing an important role at the interphase between the care seekers and the care providers, which would indicate the responsiveness of the Health Service and ultimately the fulfillment of the expectations of the patients. The Guidance gained from this booklet will assist you to achieve this difficult but essential part of your training. Dr. Athula Kahandaliyanage Secretary Ministry of Healthcare and Nutrition

Nimal Siripala De Silva Minister of Healthcare and Nutrition

Message from the Director General, Ministry of Healthcare and Nutrition While greeting you as young members of the medical profession, I am glad that you would have the advantage of meeting, examining and treating the large number of patients attending the Ministry of Health Hospitals which eventually will transform into a vast deposit of clinical experience for your future guidance. At the commencement of your internship I whish to emphasize that it is very important to recognize that you are expected to treat all your patients with dignity, respect and kindness, to which they are rightfully entitled to. This publication summarizes some of the key issues that would guide you to look after these patients in a manner that you could be proud of. Dr. Ajith Mendis Director General Ministry of Healthcare and Nutrition

You and Your Patients

By Dr. S. Terrence G.R. De Silva, MBBS, DPS, DFM, DLSHTM, MSc, (Lond), MD Deputy Director General (Medical Services) I (Former Director of the National Hospital of Sri Lanka, Colombo) A time tested system of providing medical care existed for a long period. The history taking, the physical examination and a few basic investigations were done to arrive at the diagnosis of ailments. However, some of the recent advances in medical science, the technological innovations and the different teaching methods followed in various medical schools specially, outside Sri Lanka, have threatened the existing low cost patient care system. The young doctors today, tend to bypass the history taking & physical examination and try to rely mainly on the laboratory & radiological investigations which are very expensive and at times beyond the capacity of our hospitals. In addition, there are increasing public expectations and demands for high quality service. Many of the patients have access to medical information via the improved information technology and they show an increased desire to involve with the decisions related to their healthcare. As far as the health indicators are concerned the health service of this country is almost in par with those in the developed countries. People of this country are generally satisfied with the health service and they have placed their trust and confidence in this system. Nevertheless, in recent times, the attitudes of those in the sphere of health towards their patients have left much to be desired. Perhaps this is part and parcel of the situation in the society at large. It is the duty of everyone to protect our health

system. For this it is necessary to strengthen the positive attitudes and qualities among the health care staff. This booklet A Word of Guidance to Medical Interns was prepared with the aim of making an attitudinal change among the young doctors. What Your Vision & Mission should be? Having successfully completed your school education, you made up your mind, sometimes against many odds, to become a successful medical professional in this country. Sometimes it may have been an aspiration you have had over a number of years. Becoming a successful medical professional was your deep rooted vision and by this time you have been partly successful in realizing this vision. As a medical professional it is your duty to care for and treat with kindness, love and empathy, your fellow human beings who are ill and incapacitated. This is your mission as a medical professional. In order to make your vision a complete success you must ensure that you carry out your mission with dedication and commitment. The Ministry of Health respects your vision and values your desire and decision to carry out your mission. Recognizing your vision and the mission stated above, the Ministry of Health extends you a warm welcome to the Ministry. Our Ministry is the prime healthcare provider of this country. You are today commencing a journey with a small step but a giant leap forward. Let me emphasize at this stage that there is no red carpet for you to tread on, but a long and yet satisfying and meritorious path ahead, if you would only dedicate yourselves. 9

Those medical professionals who are already serving the Ministry of Health and the Professorial Units attached to the Faculties of Medicine are always ready to help you to carry out your mission and to realize the goals you aspired to achieve in your life. The Internship Appointment I am sure from the day your name appeared in the list of students who have passed the final MBBS examination on the Medical Faculty notice board you have been eagerly waiting for the internship appointment. You would have been extremely thrilled on this day over your success at the examination and realization that henceforth you will be addressed as Doctor. We have no doubt that you and all your family members would have enjoyed this happy moment. Going through your life, the day you assume duties as an intern house officer is going to be another memorable day. However, internship is not plain sailing. Only once you commence the internship you would realize the challenges that come with it. You will have to spend long sleepless hours, attend to virtually never ending ward work and face criticism and sometimes the blame from your superiors including the Consultants & the Senior Registrars (who actually have gone through the same hardships before you). You may feel like a slave, a laborer, a prisoner, and at times be in a confused emotional state. Do not get disheartened about this, but think in terms of perseverance and endurance. The Internship period is a compulsory training and I should say that to most of us, it is really a hard time. During the Internship you will feel the taste of what is available for you, sometimes sweet, sometimes sour, sometimes bitter and all blended with ingredients of hard work, personal sacrifices, mental fatigue frustration, and of course the 10

satisfaction realizing that you have helped a human being to alleviate his suffering. In the midst of all this you might even question yourself as to your choice of the medical profession. You might even blame those who encouraged you to become a medical doctor. I have seen some interns comparing their lives with those of their schoolmates who are serving in different fields, with much free time and the ability to spend to enjoy life. You must not be discouraged at this stage and must develop a positive attitude and gain strength to face all these situations. Accept your internship as an opportunity to become a successful medical professional in future. Many years later when you walk down the memory lane, you will recall the sad and happy moments, the lessons you learnt from your superiors and also from the patients, the skills you were able to develop and the superiors who were there to guide you and all other things that made you richer in experience. Most of the Senior Registrars and Consultants who trained you and sometimes blamed you would become lifelong friends. Later on you will realize that most of them are with you at times of distress and need, throughout the rest of your life. This is the beauty of the strenuous training. At present you may be at the bottom rung of the professional ladder, and you have to climb step by step and one day you will reach the top rung. I must emphasize that you may have to continue to struggle during the rest of your career too, but am sure will improve as you go along.

What is Special about Your Work in the Health Sector? The Healthcare Service is saddled with the responsibility of caring for and pursuing human life. First of all, think of the crucial role you play in such an esteemed noble service and come to terms with the importance of the task you are called upon to perform. Naturally, the position you hold in the Health Care Service provides you with a livelihood. Yet, in this noble service, you have to accept your position, as more of a calling than a job, giving you an opportunity for a meritorious service. The Specific Nature of Your Work The Health Care Service has its own share of public liaison activities. The hospital is a busier place than a government office which serves a limited clientele. Work at a hospital is of a more arduous and one may face diverse problems. It is often difficult to provide a service to please everyone and to meet the expectation of people from all walks of life and holding varied requirements. It is more so, since the people who come to a hospital for treatment are patients ailing from various illnesses. As an intern and thereafter as a medical officer you may have certain specific difficulties. These include the restrictions in obtaining leave even for an urgent personal matter, obligation to report for work even on Sundays and public holidays which is a facility enjoyed by the other state employees, to work on night shifts and the need to report for work during such crisis as disrupted transport services and being called upon to work on unexpected work shifts in emergencies. The medical professionals like anybody else have to face personal or family problems. Despite all these, you are expected



to work in a spirit of dedication. Whatever your personal constraints are, when you are on duty at the hospital, your mind and heart should go out to the patients. This is the nature of the work of a medical professional. Communicating with the Patients One of the important and challenging part of providing care during the internship and thereafter as a medical officer or a specialist is establishing a good rapport with patients and their relations, and communicate with them in such a way to make them recognize your commitment and ability to provide care using your skills and knowledge. The first impression of any person coming into contact with you is governed by the way you appear and the way you carry and present yourself. You have to be neat, clean and tidy and with your hair well combed and also face well shaven or beard trimmed. It is important that you conduct yourself like a professional. The way you talk, the way you smile, the way you walk and the way you behave in front of your patients, relations, superiors etc. should generate respect not fear or disgust. The patients generally have a perception about how a doctor would look like. Therefore to start with your appearance and behavior should be like a doctor.

Bestow Compassion on Patients Compassion is a must you should have. Your smile costs you nothing, but it makes you a pleasant and comfort person to the patient. Go about your work with a smile on your face. What good will be done by blaming the patient instead of using kind simple words when you want to advice, which will be of more effective. In patient care, flexibility is of vital importance. Always try to accommodate the requests of patients as far as possible, because then only they will be able to comply. When you talk about such matters as personal cleanliness, or in instances of giving medical advice, do so after calming your mind and without anger. When you explain the matters related to an illness to the patient or to his relations, use the simplest language possible, the common, conversational language understandable to layman. Not only is the medical terminology may be beyond their grasp, they may be further confused by such words, which may be misunderstood in a way totally different from the way you meant them to be. It is necessary to address the patients with due respect and it is always better to address the patient by name, and ensure that his dignity and self-respect remains unsullied. The words that make the patient pleased can be used. To cite examples, addressing a patient as Mr. or Madam may go a long way to win the confidence of patients and their relations. Using polite words as please, help to make patients conduct themselves well during their stay at the hospital. Similarly, in case of an inadvertency on your part, do not hesitate to say sorry with an explanation. Making an apology is not something to be ashamed of when you have done a mistake.



Who is the VIP at the Hospital? The VIP at the hospital is the patient and no one else. A hospital could be considered as a sacred place. In the days gone past, patient care and cure were associated with temples and churches. A patient enters the hospital in a physically weak and mentally depressed state. Your patient expects from you the same affection, kindness, compassion, attachment and love that a child expects from his mother, If you can ensure that this expectation is fulfilled, the patient will think of you as having divine qualities. If he or she feels so, it will give you a satisfaction of being special among others. The blessings the patient invoke will surely fall on you and your loved ones. See whether the meaning of the adaptation of this poem taken from a Sinhala didactic work is relevant to you. we;;a ke;;a mrf,dj iqofkks uy; yf<d;a fhfyls ml fkd;ndu is; kef;d;a tmrf,dj bkajk wjev ke; wef;d;a ke;ehs m l< yg fjhs m; ^iqNdIs;h& Ye! good ones, be there a world to come or not Shed evil with no trace of such in mind Good does no harm in this world or next Evil always follows the evil doer The patient will be pleased with your care only if it is tempered with a feeling pouring out from the bottom of your heart. The following comments are often heard at gatherings of bus stands, temples or even at parties. You will not like to be the

one that caused them to utter these remarks about the health service. They have no respect of our privacy They order us around and put us through all sorts of procedures without even telling us what they are doing or why They dont care if we are upset, or scared, or in pain; they just do what they like and pass us on to somebody else. It is your duty to do everything possible to free the hospitals of the negative image and help sustain the trust and confidence placed by the people in our health care system. An Alien Environment A patient enters a hospital unwillingly away from his home environment. As such he is often uneasy to begin with. It is your duty to treat him with an understanding of his predicament and respect. It is likely that the patient or his loved ones may blame you for no fault of yours. It is possibly part of their grief reaction. Do not get disheartened by the words of those who are going through some disturbance of mind. Think of the Patients Agony What the Patient is Going Through It is unfortunate that only a few of us are seriously concerned about the fear and pain a patient experiences in going through a multitude of procedures and examinations which at times are uncomfortable. Even when pain can be alleviated easily during such procedures, it is unfortunate that some do not bother to provide such relief.



Do unto the patients what you like others do unto you, in similar situations. Keep in mind the fact that one kind word from you gives the patient more relief, than a drug worth thousands of rupees. Soothe the Pain In the story of Mother Theresa it is stated that one day she found a dying woman half infested with maggots and bitten by rats. Mother Theresa sat besides her stroking her head gently till her death. Did you take to medicine to act in the same spirit? Of course Mother Theresa later on in her life became a willing companion for the dying; washing their wounds, soothing their sores and preparing them for death with dignity. Patients like to know about their condition. Thanks to the free and compulsory educational policies of the government of Sri Lanka 98 % of people are literate. Patients know something about illness and want to know what is wrong with them, why it happened, what more will happen and most importantly what we are going to do with them and whether any further problems will happen because of what we do. We should not assume that simply because we are doctors or because we are providing free medicine they would accept our word without questions. As doctors we are obliged to spend adequate time to explain these matters and put their minds at ease. On the other hand the best antidote to fear is providing correct information. Once the patient realizes the actual condition of his illness (which is often less than he would have imagined) and the balanced view of the advantages and disadvantages of the treatment offered to them, it would be his wish that we should respect. This ability to communicate you would have developed over the last few years 17

of training. Additional guidance would be available in this booklet. Patient is also a Member of a Family When a patient is hospitalized, the patient as well as his family members faces a variety of difficulties. Think of a situation at your own home if the mother is hospitalized! Those at home may be deprived of the person who did the cooking and other essential household activities. If the father is hospitalized, the family may miss the sole breadwinner. When you deal with patients such factors should also be taken into consideration. Dont forget the patient is a member of a family. Give a kind and sympathetic hearing not only to the patients, but their relatives as well. Although the state provides free medicines and the services, they also contribute the same in spending for transport and other expenses out of pocket. Dont forget that every citizen of this country has contributed to the government coffers by some way or other. Take Pride of What You Have Done to Relieve the Suffering of the Sick Do your duty not merely because of the earnings you make from the job. Yours is a worthy service the value of which cannot be measured in financial terms. Undoubtedly, one needs an income for a living. Yet real happiness of life can never be bought. Go about your work in a way, that you achieve a sense of contentment in caring for patients. Dont let the patient feel it, even if you are facing inconveniences. Learn to enjoy the satisfaction of seeing your patient recover from his suffering 18

due to your efforts. Thus you achieve nobility in life as expounded by the following lines from a famous sinhala song based on religious teachings. What other happiness in the world than health, What other wealth in the world than happiness Most professionals take great pride in their professions and always strive to maintain high standards and a sense of great fulfillment in what they are doing. Similarly we who are in the health sector providing care should take pride and comfort ourselves from what we have done to help to alleviate the pain and suffering of fellow human beings. A Better Future for Our Children Today we have to play our role properly; if not the repercussions would not only on us but also fall on future generations. One day when you finally leave your stethoscope aside, if you have acted in a way that will make you contented that you have led a fruitful life, you are a person who has done your best for the country. It is certain that one day you will really enjoy that spiritual solace you desire. A few words from the song Heal the World by internationally renowned pop-singer Michael Jackson are relevant here. Heal the world Make it a better place For you and for me And the entire human race 19

There are people dying If you care enough For the living Make a better place For you and for me I wish to conclude this bit of advice, with a quotation of Albert Einstein. Only a life lived for others, is a life worthwhile.


Principals governing provision of medical care

o Each patient shall be treated as a whole, irreplaceable, unique, and worthy person o The patients safety, health, or welfare shall be protected and shall not be subordinated to organizational, staff, educational, or research interests or to any other end. o The privacy of the patient and the confidentiality of every case and record shall be maintained. o Behavior reflecting the dignity, responsibility, and service orientation of health care professionals, worthy of the publics respect and confidence, shall be practiced by all individuals.
EIGHT POINTS CONCEPT TO ENHANCE POSITIVE ATTITUDES TOWARDS PATIENTS 01. Smile The smile costs you nothing but would give much, by way of a comforting and a pleasant feeling in your patients. The patients would be on the road to recovery even before you talk to him\her. 02. Greet Greet them with a word such as "Ayubowan" and follow up by addressing him with the name. This will generate a warm feeling which would break the ice and make obtaining the history so much easier. 03. Courteousness Being polite and speaking to patients with due respect without any discrimination is very important in public service. It is necessary to answer their queries with courtesy because patients have a need and a right to know about their condition as well as about the treatment you offer. 04. Affection The patients will be pleased with you only if the treatment you offer is tempered with a feeling of goodwill and kindness that emanate from the bottom of the heart. 05. Listening The art of being a good listener is to create the space within which the patients could air their own feelings and thoughts without fear. A good listening response is often all that is needed to help patients to divulge their inner concerns and feelings.



06. Sensitive Being sensitive to patients needs is an affirmation made to the patient by the health care staff that indicates "Yes, you are sick and I understand that you are not able to do the things you would like to do, or have done in the past." We should at all times help when we can and understand that patients are the ones who have been inconvenienced by the illness. 07. Be Smart Being presentable, smartly dressed and a having pleasing personality is important to positively impress your patients and will increase the patients compliance towards recommended treatment. 08. Be Prompt. Patients need an answer for their suffering and will not wait till the formalities and investigations are completed. Being quick in providing treatment, even to provide temporary relief, is the expectation of all patients.

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Avoiding Medical Errors

Dr. Lakshman Senanayake
FRCOG, FSLCOG, MA Consultant Obstetrician & Gynaecologist Consultant Hospital Efficiency & Quality, SLHSDP

What are Medical Errors? 06. O E '. F. F k P' FN OA. O J C P M K . 07. K K E K O FK. 08.
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A medical error is an adverse event that could have been prevented if adequate care had been taken by the care provider, considering the current state of medical knowledge. (1) These do not include some adverse events due to treatment such as side effects of cytotoxic drugs which are undesirable though not entirely unexpected.

Are they Common? QI FJ K F O In November 1999 the report of the Institute of Medicine (IOM) of USA by Lucian Leape and David Bates entitled To Err Is Human: Building a Safer Health System, focused a great deal of attention on the issue of medical errors and patient safety. The report indicated that as many as 44,000 to 98,000 people die in hospitals in the United States of America, each year as the result of medical errors. (2)




100000 90000 80000 70000 60000 50000 40000 30000 20000 10000 0






Medical Traffic Accidents Plane Errors Accidents at work Crashes

Can they be prevented? An Australian Study on Adverse Events in hospitals of New South Wales found that adverse events were preventable in more than 50% of cases. A study in U.K. on Adverse Events in Obstetrics and Gynaecology found that more than 50% are preventable. (3)

Surprisingly in Canada 60 people die due to airplane accidents every year where as 24,000 die from medical errors. National statistics on medical errors are not available in Sri Lanka, but each of us would know at least of a few instances either among our relations, friends or patients who had suffered on account of a medical error. I can think of one of my batch mates who had a cautery burn after a minor operation which prevented from going for work for more than two months and a relation who suffered from a wrist drop due to nuropraxia because of the wrong positioning at surgery. Recent Media reports of shocking instances of amputation of the wrong leg or accidental cutting off of a finger is still fresh in our minds

All medical Errors are preventable

To err is Human. To cover up is unforgivable. To fail to learn is inexcusable.

Therefore it is important to learn from them and take measures to prevent them rather than Blame or Shame others Why do Medical Errors happen? Medical Errors are mostly due to a combination of factors rather than one single factor.



Human Factor Human Error is the aspect which is often highlighted and you and I as care providers are directly responsible for their occurrence and we have to individually face the consequences. Although every one knows that health care providers do not cause harm to patients intentionally, the grief reaction of the victim and his or her relations usually results in blaming and shaming the care providers and sometimes even physically assaulting them. Human Errors can be considered under three headings Slips and lapses (unintentional) Mistakes (intentional incorrect action) Violations (intentional deviation from safe practice)

in the post op ward. The next call you may get may be that the patient has collapsed and bad. Mistakes These are intentional and occur when a course of action that is incorrect is decided on, and therefore does not have the desired result or even a harmful result. Rule based: For example, syntometrine is given for active management of the third stage in a woman with hypertension and she subsequently has a fit. A good rule has been used in but in the wrong situation. Knowledge based: There is a lack of knowledge. Treatment is decided on without being certain or asking a senior person .It does not have the desired effect. Or worse a harmful effect Some times a colleague or a nursing officer may point out the error but the person may not pay attention due to his ego or ignorance. Violations These are intentional deviation from safe and accepted practice or given instructions Routine: Cutting corners or taking short cuts, e.g. Not entering the instructions in the BHT but verbally asking the Nursing Officer to do it. Reasoned Interne considers that he can do a forceps for fetal bradycardia in the delivery room without informing the senior because the FHS is low or he withholds giving blood to a patient with a PPH as the blood pressure is normal although the loss is more than 1000 mls and has a tachycardia. 32

Slips and Lapses These are unintentional and may happen because of: Failure to recognize: A sign, investigation finding or a change in the condition of the patient. E.g. Not recognizing that the patient is pale indicating internal hemorrhage one may loose the patient brought to the hospital after a fall from a height. Result is Patient is lost. Failure to pay attention to a finding: Findings such as tachycardia, or tachypnoea may have been recognized but due attention such as informing the consultant, starting a transfusion or correcting the hydration may not have been done Result is Patient is lost. Failure in Memory: An important action may not be done as it has escaped your memory. Giving a blood transfusion to a post operative patient to compensate the blood loss at surgery 31

Reckless: Harm is foreseeable but not intended, e.g. Going on making multiple attempts at a procedure such as Liver Biopsy without calling for help or imaging assistance or Going on with uterine massage or Oxytocics for PPH without calling the Seniors or the Consultant. What can you do to prevent them Happen? Communication errors Communications include not only the verbal discussions but the written communications via the entries in the BHT. Your notes on the BHT are vital not only for the safety of the patient but for your safety as well, in the event of a complaint or litigation. The entries on the BHT must be clear, legible and in complete sentences. The comments on surgical decisions and other invasive procedures should indicate: Justification on what grounds the decision is made What the decision is Any instructions others need to follow Wishes of the patients regarding this decision Coordinating with other departments The welfare of the patient depends on the Team Effort .Though a patient is under one Consultant, he may desire opinions and advice from other specialists. Therefore coordinating the communications between different specialists and departments is vital and is the responsibility of the house officer. This should be attempted promptly politely and personally by yourself. 33

Other Important Issues The prescriptions should be written clearly with the Generic name of the drug in capitals and the dose and the frequency of administering clearly indicated. One patient in USA died because the cytotoxic drugs were administered four times a day when the instructions meant that the dose to be given over a four day period. Lack of clarity in the entry caused the death. Names of the drugs may look and sound similar. E.g. Ergometrine used in the past for PPH. and Ergotamine for Migraine, Zantac (ranitidine) for heartburn, Zyrtec (cetirizine) for allergies, Celebrex (celecoxib) for arthritis and Celexa (citalopram) for depression. Do not assume that that other person would do something but clearly indicate and specifically on the BHT requesting him to do it. If informing another care provider is urgent, do it then and there. You may forget it later. Keep a check list or a record of things you have to do and tick them off as you complete. Labeling Errors Always check the name of the drug on the vial/bottle before administering the drug. Do not assume that it is the drug because it is in the same cupboard or the same container. Check the details on the label of the blood packs before starting the Transfusions of blood and blood products. Do not assume that it was checked by some one else. One who starts the transfusion is responsible. Check the name and the identification on laboratory report, the X-ray or other reports before acting on them. Address the patient by his name as given in the BHT. Whenever you communicate with him. 34

Avoiding Medical Errors in Surgery

o Talk to the patient by name and check with him/her in the verification process. o Discuss with other members of the surgical team. o Adhere to the protocol of. the Unit or the instructions of your Consultant. o If there is a deviation from this, inform the Consultant immediately. o Mark the site of the Surgery accordingly. The following steps are recommended to be taken at every surgery. Verification (To be done in the ward) Purpose: To ensure all required documents and requisites are complete. o Confirm identity of the patient with the surgical procedure o Pre operative Investigations o Other Requirement s Blood X match Prosthesis etc o Informed Consent mentioning the site and side of the surgery Marking the site of the Surgery (To be done in the ward) Purpose: To specifically identify the site of surgery in order to clearly indicate the site of Surgery o For procedures involving: o Rt/Lt distinction, the side Right/Left must be clearly marked o Multiple structures such as fingers should be identified o Intended site must be marked so that it would be visible after covering the patient with towels. E.g. Label on the forehead

Source Ref 4 A mistake made in performing surgery on the wrong side of the leg could be disastrous not only to the patient but to the surgeon as well. Though this kind of errors is rare, it continues to happen in different parts of the world. A hospital in USA reported that three patients had surgery done on the wrong side of the head within one year. (5) The points at which errors may happen in surgical procedures is given in the chart which analyzed errors in USA Higher Risk of Medical Errors Patients undergoing multiple surgery Multiple surgeons taking part Rushed to finish the surgery Basic principles in preventing wrong site, wrong procedure, wrong person surgery o Avoid relying on memory alone. o Use a Check List to keep track of essential items that needs to be done before surgery. 35


Final Verification Immediately before starting the operation in operating theater Time Out Purpose: To conduct a final verification before starting the surgery Check the name of the patient from him/her and confirm the surgery/site/side preferably with the participation of another member of the team. Procedure must be started after this had been done. If there is any doubt the consultant should be informed immediately before starting the surgery. Getting Consent for a surgical or other procedures Informed Consent includes the following three parts and is the responsibility of a medical officer who is, often the intern house officer. The first part is the explanation to the patient, in a language that the patient can understand, of the nature of a proposed procedure or treatment, its potential risks and benefits, reasonable alternatives which may be available. The second part is ensuring that patient understands what has been explained (to the best of the patient's intellectual capacity); the patient accepting the risks; The patient giving his or her consent to undergo the procedure or treatment Finally, the process must be documented clearly in a language that could be understood by the patient 37

References: 1 Encyclopedia of Surgery: A Guide for Patients and Caregivers 2 Medical Errors Scope of the Problem Agency for Health care Research and quality 3 Risk management in obstetrics; Current Obstetrics & Gynaecology (2005) 15, 237243 4 Sandra Strickland Preventing Medical Error Wrong Surgery Preventive Action Vol 17 No 12004 5


Blood Bank
..., Director, National Blood Transfusion Service All Intern House Officers must report to the Blood Bank of their institution as early as possible for an orientation programme. Instructions on basic Blood Bank procedures are given below for easy reference. ABO & Rh-D Grouping of Patients & Antenatal Mothers Materials Required Specimens: Clotted blood sample or EDTA blood sample. Reagents: Anti A, Anti B, Anti AB, Anti A1 Anti D - monoclonal IgM Anti D Reagent red cells A1 cells, B cells, O cells N. Saline/PBS (Phosphate Buffered Saline) Test tubes, Pipettes, Metal tube stand Table top centrifuge Report forms Registers for recording results Procedure 1. Check the sample and request form to ensure that the patient identification is correct. 2. Label the sample and request form. 3. Centrifuge the sample at 1000- 3000 rpm for 3 min to separate serum. 39 40

4. Prepare a 5% cell suspension (can be prepared by adding 19 drops of saline to 1 drop of patients red cells 5. Arrange 8 test tubes on a test tube rack and label with patient & test identification as following. E.g.: Pt 1 1 1 1 1 1 1

Compare and confirm the cell grouping results with the serum grouping results. Gently resuspend the cell button of the Rh D typing tube and look for agglutination. If no agglutination seen, repeat the test with 2 drops of same Anti D. Test for detecting weak D is unnecessary for patients when using monoclonal IgM antiserum.

5% cell Suspension A

Anti B

Anti AB

Anti D

A1 c



Interpretation Agglutination of any cell grouping tube and haemolysis or agglutination on serum tests constitutes a positive result. The expected agglutination reaction for positive tests is 3+ or 4+ in cell tubes. Agglutination in serum tubes is often weaker. The reaction can be enhanced if incubated at room temperature for 15 min. A smooth suspension of red cells after resuspension of the cell button is a negative result. In serum grouping tubes, if the supernatant (before resuspension) is pink/red and if the size of the cell button is smaller or no cell button is seen it indicates lysis and is a positive result. ABO Grouping Anti Anti A B 0 0 3/4+ 0 0 3/4+ 3/4+ 3/4+ C = clumps Anti AB 0 3/4+ 3/4+ 3/4+ L = lysis A1c C/L 0 C/L 0 Bc C/L C/L 0 0 Oc 0 0 0 0 Interpretation Group O Group A Group B Group AB

Add one drop of anti A, anti B, anti AB & anti D to first four tubes. Add one drop of 2- 5% cell suspension of red cells to be tested. Add two drop of patient serum/plasma to test tubes labeled as A1c, Bc, Oc. Add one drop of A1 reagent red cells to tube labeled as. A1c Add one drop of B reagent red cells to tube labeled as Bc. Add one drop of O reagent red cells to tube labeled as Oc. Mix the contents of the tubes and centrifuge at 1000rpm 20 seconds or keep at room temperature for 5 min. First take the cell grouping tubes and gently resuspend the cell buttons and examine for agglutination Grade and record the results on worksheet Take the serum grouping tubes and first examine the serum overlying the cell button for evidence of haemolysis. Gently resuspend the cell button and examine for agglutination. Grade and record the results on work sheet.



Rh D Type Anti D (not detecting Dvi variant) + 0 Interpretation Positive Negative

. Microscope . 37C water bath Specimen . Clotted blood sample of patient . 5% suspension of red cells prepared forms a selected donor unit. Reagents . 0.9% saline . 22% Bovine Albumin . Anti human globulin (AHG) . LISS Additive . PBS Glassware . Glass test tubes . Glass slide . Pipettes Miscellaneous . Disposal box . 2 plastic beakers Test tube racks Procedure 1. Give a serial number to the testing sample and the request form before commencing the procedure. 2. Group patients sample for ABO and Rh D as per REF/ SOP/ 02..and accordingly select a group specific blood unit/s for cross matching. 3. If the presence of an antibody is confirmed, select relevant antigen negative blood unit/s and/or if patients phenotype is known select blood units according to the phenotype.

After interpretation, the blood group must be compared with previous records, if available. If any discrepancy between present group and previous group is encountered, request for a second sample and confirm. If any discrepancy between serum and cell grouping is encountered, repeat the test using washed cells. If the discrepancy persists, consider the previous history of Transfusions If there is no discrepancy, record the blood group of the patient.

Documentation Enter the results of the patients grouping in the Pre Transfusion Testing Register. Complete and counter sign a Blood Report. Pre Transfusion compatibility testing Material Required Equipment . Refrigerator to store samples and reagent at +2C to +6C . Table top centrifuge 43


4. Label test tubes as D1, D2 .according to the number of donor blood units requested for the patient. Add one drop of donor cells to each labeled test tubes. NISS Method 5. Add three/two drops of patients serum to all test tubes. 6. Add one drop of 5% suspension of cells from donors to the relevant test tubes 7. Mix the contents and incubate all test tubes at 37oc for 45 minutes. 8. Take out and centrifuge at 250g for 20 seconds. 9. Look for haemolysis and then gently disturb the cell button to note agglutination of cells. 10. Grade and record the results. 11. Add PBS to fill 2/3 of all test tubes. 12. Centrifuge at1000g for 1 min. 13. Decant the supernatant PBS. 14. Repeat the same washing steps twice. 15. After the last wash, add two drops of poly specific AHG to all the dry cell buttons in each test tube. 16. Gently disturb the cell button to note any agglutination of cells. Record results in the work sheet Saline Albumin Cross match 1. Take two test tubes each for each Donor pack & label them as Saline (S) & Albumin (A). 2. Add three/two drops of patients serum to all test tubes. 3. Add one drop of 5% suspension of cells from donors to the relevant test tubes 4. Add 1 drop of 22% bovine albumin into the tube labelled as albumin mix the content & incubate at 37oc water bath for 30 - 45 minutes. 5. After incubation period take the tubes from the water bath & centrifuge at 250g for 20 seconds. 6. Look for haemolysis & or agglutination microscopically. 7. Grade & record results on the request form. 45

8. If there is no agglutination or haemolysis in both tubesproceed to AHG test on Albumin tube. 4.1. Shake the Albumin tube gently to disturb the cells at the bottom. 4.2. Fill he tube with normal saline. 4.3. Centrifuge at 1000g for 1 minutes 4.4. Decant the supernatant completely to get a dry cell button. 4.5. Repeat above steps two more times 4.6. After the last wash, disturb the cell button 7 add polyspecific AHG reagent 4.7. Centrifuge the tube at 250g for 15sec. 4.8. Look for macroscopic/microscopic agglutination 4.9. If there is no agglutination the cross match is compatible. (Negative IAT results should be validated with Coombs control cells, if available.) LISS Method 1. Take a test tube each for each donor pack. 2. Add two drops of patients serum to all tubes. 3. Add one drop of 5% suspension of cells from donors to the relevant test tubes. 4. Add 2 drops of LISS Additive into the tube mix the content well & incubate at 37oc water bath for 15 - 20 minutes. 5. After incubation period take the tubes from the water bath & centrifuge at 250g for 20 seconds. 6. Look for haemolysis & or agglutination microscopically. 7. Grade & record results on the request form. 8. If there is no agglutination do the indirect AHG test mentioned in saline Albumin method & interpret the results. 9. For all the washing steps use fresh normal saline or PBS solution. 10. If there is no agglutination the cross match is compatible. 46

Pre Transfusion Compatibility Testing for Infants Interpretation 6.1. If cross match is compatible 6.1.1. Write a Compatibility report 6.1.2. Attach a reservation tag to the blood pack & keep the blood pack in the correct refrigerator 6.1.3. Preserve the tested sample for 7 days in the refrigerator. 6.2. If the cross match is incompatible 6.2.1. Recheck the patients blood group & donor unit 6.2.2. Do cross match with another unit of blood 6.2.3. If still incompatible contact MO on duty at Immunohaematology Reference Lab, NBTC. Documentation Enter the results in the pre-transfusion compatibility testing work sheet and register. If the cross match is compatible, . Write a compatibility report and sign. . Attach a compatibility label to the blood unit. Procedure 01. Wash the babies blood sample 3 times with fresh 0.9% saline or PBS 02. Prepare a 5% suspension of red cells after the final wash 02. Using the suspension, carry out the ABO and Rh grouping as above. 03. Carry out the ABO and Rh grouping of the mother as above. 04. Select blood for crossmatch as follows, . Select blood compatible with the ABO and Rh grouping of the baby and the mother (refer table annexed). . Otherwise use group O Rh compatible units . Select blood within 5 days of collection . Avoid using blood donated by blood relatives 05. Perform the cross match using mothers Serum and donor cells as per SOP/REF/09 Infant Group B Blood unit ,O Blood unit B,O Blood unit B,O Blood unit O


Group A Group B Group AB Group O

Group A Blood unit A,O Blood unit O Blood unit A,O Blood unit O

Group AB Blood unit A,O Blood unit B,O Blood unit AB,O Blood unit O

Group O Blood unit, O Blood unit O Blood unit O Blood unit O



Documentation Enter the results in the Pre-transfusion Compatibility work sheet. Write a compatibility report and a reservation tag.

Communication skills for Doctors

Dr. Deepthi Samarage, Head of Dept. of Medical Education / Faculty of Medical Sciences, University of Sri Jayawardanapura

Introduction Good doctors communicate effectively with patients. They identify patients' problems more accurately, and patients are more satisfied with the care they receive. Doctors do not communicate with their patients as well as they should. When doctors use communication skills effectively, both they and their patients benefit.

Doctors identify their patients' problems more accurately. Patients are more satisfied with their care and can better understand their problems, investigations, and treatment options. Patients are more likely to adhere to treatment and to follow advice on behaviour change. Patients' distress and their vulnerability to anxiety and depression are lessened. Doctors' own wellbeing is improved. Doctors with good communication skills have greater job satisfaction and less work stress

Key tasks in communication with patients

Eliciting the patient's main problems, the patient's perceptions of these and the physical, emotional, and social impact of the patient's problems on the patient and family



Tailoring information to what the patient wants to know; checking his or her understanding

attending to physical aspects only switching the topic "jollying" patients along

Eliciting the patient's reactions to the information given and his or her main concerns

Determining how much the patient wants to participate in decision making

Reasons for patients not disclosing problems

belief that nothing can be done reluctance to burden the doctor desire not to seem pathetic or ungrateful concern that it is not legitimate to mention them doctors' blocking behaviour worry that their fears of what is wrong with them will be confirmed

(when treatment options are available) Discussing treatment options so that the patient understands the implications

Unfortunately, doctors often fail in these tasks. Evidence shows that only half of the complaints and concerns of patients are likely to be elicited. Often doctors obtain little information about patients' perceptions of their problems or about the physical, emotional, and social impact of the problems. When doctors provide information they do so in an inflexible way and tend to ignore what individual patients wish to know. They pay little attention to checking how well patients have understood what they have been told. Less than half of psychological morbidity in patients is recognized. Often patients do not adhere to the treatment and advice that the doctor offers, and levels of patient satisfaction are variable. Blocking behavior of doctors
offering advice and reassurance before the main problems have been identified explaining away distress as normal

Each of us has our own unique way of relating with others and it is important to become aware of the impact that our style has on our relationships. As a doctor you have a particular responsibility to develop an interpersonal style that will enhance the effectiveness of your relationships and facilitate effective communication with your clients/ colleagues. We believe that a meaningful relationship and effective communication is a fundamental component contributing to the well-being of the client/ colleague. Attending: Physical and Psychological presence Attending is the process by which the doctor pays close attention, both verbally and nonverbally, in such a way that the client/colleague feels listened to, care about, and accepted. Often doctors have developed ways of relating nonverbally 52


which discourage clients/ colleagues from becoming engaged in interactions with them. Certain facial expressions such as frowns or curled lips, or other body behaviors such as yawning or squirming then to inhibit the interaction. By developing awareness and practicing those behaviors which are perceived by most people as signs of attention and interest, the doctor demonstrates physical presence and a willingness to become involved in the interaction. Physical attending includes facing the client/colleague making eye contact, leaning forward toward the client/colleague and having an open and relaxed posture. When the doctor pays close attention to the client/colleague he/she demonstrates respect, interest, involvement and caring, good attending is also a powerful reinforces as it encourages the client/ colleague to become more involved in the communication process. Empathy Empathy is the most critical element in a helping situation and is the backbone of the responding skills. Empathy is the ability to understand the ideas and feelings of another person. By using empathy, the doctor can enable the clients/colleagues to see themselves and their situation more clearly. Empathy then enables the client/colleague to feel understood. As a doctor who is skillful with empathy, you are able to stand in shoes of another. You can see and hear how clients/colleagues feel and think, and are able to show the client/colleague that you understand their feelings and situation. Listening Listening is the key to understanding the meaning of anothers experience. Why is it then, that messages are not heard accurately and miscommunication abounds? Factors that interfere with listening. 53

Listed below are some common factors that could interfere with your listening ability. Preoccupation Often we are distracted from listening by thinking about other things. We allow our minds to focus on our concerns rather than the person we are listening to. Speaking vs. listening At times we are more intent on speaking that listening. We are so anxious to tell things the way we see them that we dont truly hear what the other person is saying. Judging vs. listening

There are many daily situations which encourage us to judge what people are saying. To be helpful in a situation demands an ability to be accepting. Thats difficult to do if you are used to being critical. In every conversation there are two components to listen for: Content: what the client/colleague is talking about Feelings: how the client/colleague feels about the situation.

Respect Respect, in essence, refers to a belief in the value and potential of the other person. Respect is communicated more by attitude than by specific response. The respect the doctor shows for the client/colleague will enable him to share his concerns more openly and easily. Warmth Warmth is a physical expression of empathy and respect. It is generally communicated nonverbally in such ways as: eye contact, facial expression, touching, tone of voice, posture and 54

gesture. Ordinarily, nonverbal behaviors, such as eye contact, facial expressions, tone of voice, etc., are not consciously exhibited. However, under conditions of attention and practice, you can increase your awareness of your own nonverbal expressions and modify your nonverbal behaviors in the direction of increased warmth. Clarification In interactions with a doctor, the client or colleague presents many concerns, ideas and feelings. This is often done in an implied way, perhaps through humour or deliberate vagueness. Clarification is a method of making the other persons message explicit. Clarification is also a method of confirming the accuracy of your perceptions about the other persons message. As doctors, we often make the assumption that understanding is occurring without validating our perceptions. This can lead us to making assessments based on inaccurate information. Clarification can serve to correct misperceptions before they become misunderstandings. Summarizing In interactions with clients, the doctor may find that many ideas and feelings are presented. Summarizing involves a process of tying together relevant core materials that have been presented in a fragmented way. The main purpose of summarizing is to systematically highlight the critical aspects of the clients statements and behavior. We have attempted to provide you with some concepts that we think are necessary for effective communication. How you use these tools will depend on your personal beliefs and values as you respond in a helping relationship. We cannot make you communicate more effectively, the desire has to come from within. Its now up to you! 55

Guidance in issuing medical certificates

For detailed information on issuing medical certificates, please refer the following circulars. General Circular No. 1006 issued by director of health services on 20 th June 1979 General Circular No. 1086 issued by director of health services on 7th May 1980 General Circular No. 1481 issued by Director General of health services on 21st October 1986 General Circular No. 1481 A issued by Director General of health services on 12th November 1986 (Maternity leaves) Public administration circular 4 / 2005 ministry of public administration and home affaires 3 rd February 2005 Given below are few salient points regarding issue of medical certificates Those authorised to issue medical certificates in Teaching, Provincial General, District General and Base Hospital are; (I) Wards: Physicians, Surgeons, Paediatricians, Obstetricians, all the other specialists and House Officers under the direction of their respective consultants. (II) Clinics: Specialist Officers (III) O.P.D: Physician and Surgeon between the hours fixed by M.O.I/C, O.P.D. for those who attend the O.P.D genuinely and primarily for treatment. Medical Officers O.P.D. only in case of medical and surgical emergencies, at all hours.


1) Confirming the Identity of the patient to whom certificate is issued; 2) Medical Certificates on Form Medical 170 and 331 are issued free; 3) The Medical Officer should be satisfied, before issuing the Medical Certificate that the incapacitation resulting from illness or injury is such that the officer/ employee is unable to perform his/her normal duties; 4) The leave granted should be in keeping with the incapacitation; 5) Medical officers shall not recommend leave in excess of a month at a time and extension of a leave shall not be recommended for more than a month in the first instances and more than two weeks in the second and third instances. Medical leave beyond the period of 3 months would necessitate the individual being sent before a Medical Board; 6) Medical Certificates issued by private Medical Practitioners as well as those issued by Ayurvedic Medical Practitioners should not be endorsed by Government Medical Officers; 7) The Medical Certificate should not cover more than five days past absence under any circumstances, except in the case of an in-door patient to cover a period of stay in hospital; 8) When officers / employees are on transfer orders utmost care should be exercise before a decision is made to recommend sick leave; 57

9) All cases in the Medical Certificate must be completed in full;

(IV) (V)

10) A Medical Certificate whether on Form 170 or Form 331 shall be promptly dispatched direct to the immediate Superior of the applicant and, under no circumstances shall a M.C. be handed over to an applicant; 11) Medical Officers of Health may issue Medical Certificate only to the following; (a) Maternity cases, (b) Staff working under the M.O.H., and (c) All cases of communicable disease. Recommending Maternity leave Salient points from public administrative circular 4 / 2005 Government has decided to grant female public officers 84 days maternity leaves with full pay, 84 days maternity leave on half pay and 84 days maternity on no pay in respect of every child birth; All female public officers whether permanent, temporally, casual or trainee are entitle to maternity leave under this section. Maternity leave with full pay o Female officer is entitle to 84 working days full pay leaves in respect of every live child birth and they will not be allow to resume duties before the expiry of 4 week after the birth of the child. 58

o In calculating maternity leave Public holydays Saturdays and Sundays falling with in such period should not be included. o In the case of a still birth or the death of a child before the expiry of 6 weeks from the child birth, 6 weeks leave from the date of child birth should be granted as special full pay leave. Maternity leave on half pay o After the exhaustion of leave mentioned in the previous para the officer is entitled to 84 days leave on half pay for her to look after the child. Maternity leave on no pay o After the end of leave approved under the previous 2 paras, it is possible to grant 84 days no pay leave only if such leave is required for the purpose of looking after the child. However, the approval of the leave would be by the Head of the relevant Department. In the case of a miscarriage the officer can avail herself of the vacation leave she is entitled to on the production of the medical certificate. After the expiration of the maternity leave obtained as described earlier the officer should be allowed to leave office one hour before the normal time of departure in order to breast feed the child provided no maternity leave on half pay has been availed of. Further, when the officer researches the fifth month of pregnancy she should be allowed to attend office half an hour later than the normal time of attendance and leave office half an hour before the normal time of departure.