title: Sepsis: Medical errors in Poland.
abstract: Health, safety and medical errors are currently the subject of worldwide discussion. The authors analysed medico-legal opinions trying to determine types of medical errors and their impact on the course of sepsis. The authors carried out a retrospective analysis of 66 medico-legal opinions issued by the Wroclaw Department of Forensic Medicine between 2004 and 2013 (at the request of the prosecutor or court) in cases examined for medical errors. Medical errors were confirmed in 55 of the 66 medico-legal opinions. The age of victims varied from 2 weeks to 68 years; 49 patients died. The analysis revealed medical errors committed by 113 health-care workers: 98 physicians, 8 nurses and 8 emergency medical dispatchers. In 33 cases, an error was made before hospitalisation. Hospital errors occurred in 35 victims. Diagnostic errors were discovered in 50 patients, including 46 cases of sepsis being incorrectly recognised and insufficient diagnoses in 37 cases. Therapeutic errors occurred in 37 victims, organisational errors in 9 and technical errors in 2. In addition to sepsis, 8 patients also had a severe concomitant disease and 8 had a chronic disease. In 45 cases, the authors observed glaring errors, which could incur criminal liability. There is an urgent need to introduce a system for reporting and analysing medical errors in Poland. The development and popularisation of standards for identifying and treating sepsis across basic medical professions is essential to improve patient safety and survival rates. Procedures should be introduced to prevent health-care workers from administering incorrect treatment in cases.
authors.affiliation: Department of Forensic Medicine, Wroclaw Medical University, Poland Department of Infectious Diseases, Regional Specialist Hospital in Wroclaw, Poland.
authors.forename: Marta
authors.initials: M
authors.lastname: Rorat
authors.affiliation: Department of Forensic Medicine, Wroclaw Medical University, Poland.
authors.forename: Tomasz
authors.initials: T
authors.lastname: Jurek
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D002648:Child; D002675:Child, Preschool; D005260:Female; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D008318:Malpractice; D019300:Medical Errors / Q000331:legislation & jurisprudence* / Q000706:statistics & numerical data*; D008875:Middle Aged; D011044:Poland / Q000453:epidemiology; D012189:Retrospective Studies; D018805:Sepsis / Q000175:diagnosis* / Q000628:therapy*; D055815:Young Adult
keywords: antibiotic management; health policy; health-care quality improvement; malpractice