Features
How to minimise medical negligence or error
by Dr K. M. Wasantha Bandara
This is a humble effort to build up on the article titled, ‘Medical negligence or error’, published in The Island on 18th July. The author of the article, Professor Susirith Mendis, who is a well reputed medical professional and an academic, has drawn our insight into unfortunate events taking place in the health system. That is very important at this time, because certain sections in the society are trying to insult and disintegrate our health system, obviously for narrow, political gains. As Prof. Mendis has emphasised it is an accepted fact worldwide that medical errors and negligence do occur in any system, although there is lack of information except for emblematic cases like the death of a young girl. However, in my opinion, any citizen may have a right to criticize any undesirable event, taking place in the process of delivery of healthcare to people, but it is very unfair to undermine the public confidence in the system. That is because our health system is considered to be Noble in terms of equity and geographical and financial access, when compared with so-called systems in most parts of the world.
I am sure there will be no one in our country to challenge the credentials of Professor Mendis to give a learned opinion on the issue. While being very much grateful and thankful to him, I must apologise to him for presenting my credentials to add some thoughts to his work as to how to minimise such incidents in the future. I am a dental surgeon who has postgraduate qualifications in three different fields, namely, Health Systems Management, Financial Management and Quality Management. I was certified as a quality manager in health care in New Zealand, and also have more than eight years of experience as a health programme manager overseas, including in certain projects funded by WHO and UNICEF. I also have participated in a number of international workshops designed to train “economic hit men” who are used to promote subtle strategies to expand the healthcare market in the name of improving the quality of care.
As such, I have personally experienced sinister attempts to disintegrate public funded health systems in favour of markets. There was one thing common in those attempts, which is what we see in our country today. These days, the attack on healthcare systems is much easier because of Zuckerberg’s army of mental slaves who can be used for the purpose free of charge. We also have experienced the role played by them to pave the way for regime change in the name of system change in Sri Lanka. The other feature which is common in these sinister attempts in exaggeration of undesired outcomes is willful cover-up of actual reasons for poor performance of the system. However, in my opinion unethical, unaccounted and corrupt practices of doctors and medical administrators do more harm to the system than errors or negligence. For example, prescribing habits of the majority of doctors are influenced by commercial interests of pharmaceutical companies, leading to over use and irrational use which is a cost to the patient as well as the nation. The corrupt practices of medical administrators in the procurement process of pharmaceuticals have undermined public confidence in the system.
I also have contributed to a research project where legal frameworks governing the healthcare delivery systems in 40 countries, including Sri Lanka, were studied. That was about more than 25 years back, and I was proud to be a Sri Lankan among western colleagues, because our system was considered to be one of the best, in terms of equity, geographical and financial access, responsiveness and relative cost of care or in other words efficiency versus effectiveness. It was also understood that remarkable performances in our health system can be attributed to free education, and civilizational inheritance, where empathy and kindness are guiding principles in social interaction in our country. Anyway, it is a fact that our people have enjoyed free healthcare, and free education ever since the origins of our civilisation.
It is obvious that we as a nation were able to achieve excellence in key aspects in our system, because of the national policy of free healthcare and hard work of health administration we had in the 70s and 80s. When compared with today’s administrative structure and the administrators themselves, the excellence of the old generation is well proved, although at that time they had no postgraduate qualifications in management, but professionalism and humanism. They took great pain amidst all constraints, especially lack of available resources, to build a system that was so effective and efficient to a level to be admired in international forums. Unfortunately, today’s generation of administrators, having postgraduate qualifications, training, and a comfortable lifestyle, have failed to uphold what their Predecessors built at difficult times than today in terms of resources. Anyway, one must be fair by accepting the fact that generational gap or deterioration of social and professional values in our society may have contributed to overall degeneration of the values in the health system.
As Professor Mendis has mentioned, and I have pointed out above, Zuckerberg’s army contributes to further deterioration of the system by posting irresponsible and indiscriminate comments in social media. In our country, although we have 6 million households, there are 8 million social media accounts and as such, there is a reasonable leverage to manipulate social opinion, and thereby social systems by a centralised system operated by external forces.
However, I will not go into details of how medical negligence or errors take place in the system, since Professor Mendis has dealt extensively on that aspect, I would like to draw the attention of the administrators and the public on the aspects of how to prevent or minimise them. Irrespective of the fact, whether the issue is negligence, error, or a kind of contributory, negligence or error, for which patients are also responsible partly or unpredictable mishap, medication error, Or poor reconciliation of medications prescribed by multiple specialists independently of each other or whatever other undesired outcome; definitely there will be a certain degree of dispute between the provider of the service and the recipient.
If the dispute is not managed properly, a minor negligence can be interpreted as criminal negligence will lead to litigation, creating more problems in the system. In the USA, it is well known that there are legal firms spying on undesirable events, taking place in hospitals and offering litigation services on the basis of sharing the compensation equally. This situation has led to unnecessary investigations and other defensive actions by the medical professionals and finally extra cost to the patient as well as the nation. That is the main reason why the US is classified as the highest spender on healthcare with poor outcomes. Healthcare spending in the US is amounting to 13.5% of the GDP, although 20 million people have no insurance cover at all for healthcare and for those who have insurance the overhead or the cost of insurance is 35%, which does not cover the cost of care.
To cut it short to be fair with The Island newspaper, which is always open for discussion, on issues of national importance, I would like to present in point form as to how to prevent or minimise undesirable outcomes in a system. Irrespective of the underlying cause of the poor outcome in the system, we could categorise those remedial measures into threefold. The first and foremost is protection of the noble fundamentals of the system, where equity, geographical and financial access is guaranteed and cost of care is contained to have justifiable balance between the efficiency and the effectiveness. People must be aware of subtle strategies, introduced to address the issue of being responsive to the expectations of the people, and finally how they facilitate expansion of the healthcare market, depriving sections of the society of basic care.
One of those subtle strategies recommended by international funders, is to divide or split the funder and provider. For example, at present, both the funder and the provider are department health, whereas if those functions are separated public and private providers have equal access to the public funds. If that is facilitated by insurance, 35% of the funds will be wasted as insurance admin cost or overhead. However, there is a need and an opportunity to improve the system further, mainly by addressing interconnected issues in the present system. One is the continuity of care and the other is a referral mechanism for specialist care, both of which can be addressed by establishing a General Practice sub system integrating the public and private out patient care.
The second approach to minimize undesirable outcomes is strengthening of legal frameworks to regulate medications, devices-etc., and to improve the accountability of medical manpower, as well as prevention and settlement of disputes. It is obvious that doctors individually cannot guarantee the safety and efficacy of medications and medical devices they are supposed to use and as such the NMRA act should provide for that. But in the present wave of allegations and counter allegations, the need to amend and strengthen the legal framework is not highlighted.
Although the draft of the amended act is in the drawers without being presented to cabinet and Parliament. Obviously, it is a well-known fact that the so -called pharmaceutical mafia takes decisions over and above the politicians and officials. That is the very reason as to why state pharmaceutical corporation is reluctant to intervene in the market to bring down the prices of essential drugs, which is contrary to principles of its founder Prof. Senaka Bibile. Also, countries like New Zealand have an independent body called health and liability commissioner established by law to intervene and settle the disputes as a mediator and to improve the accountability of medical personnel. But unfortunately, that kind of third-party approach to minimize disputes and public unrest as well as need for litigation is not discussed in the noise created by various interested parties. When there is a permanent independent mechanism established by law, it is not easy for interested parties to undermine the confidence of the people in the system.
The third approach is to improve, modify or optimize the knowledge, skills and behavioral aspects of the key healthcare personnel, for which multiple strategies can be used, including strengthening of clinical processes and practices as well as changing of management culture. There is a long list of interventions to that effect with evidence which can be easily applied in our system. Even simple measures like multidisciplinary ‘grand ward rounds’, case reviews, death reviews, medical audits in emblematic cases, and related clinical or process audits to identify common weaknesses would make a big change in the minds of the medical manpower. There is very remarkable evidence of improvements achieved by way of introducing complaint and incident registers with transparent inquiry and reporting mechanisms. Also, introducing protocols and practice guidelines to guide and unify practices that can lead to questionable outcomes have shown remarkable results.
Besides, in order to restore the public confidence a comprehensive financial and quality audit must be done to identify the weaknesses and corrupt practices in relation to registration and procurement of pharmaceuticals. It should also be mentioned that prices of medicine cannot be reduced only by price controlling mechanisms alone. In the present economic crisis, the US dollar went up by less than 50%, yet the prices of essential medicines went up in a range of 80% to 300%. Those greedy pharmaceutical traders must be countered by adequate market intervention by the state pharmaceutical corporation, which was created by Professor Senaka Bibile, for that purpose.
But, unfortunately, none of these remedial actions to improve and protect the system is not discussed by the medical associations and trade unions, except for individuals like Professor Mendis. If the fundamentals of discussion on this matter is not corrected, it can be predicted that we would get a “Gota go home – Ranil come back” type of solution to the problem.
The perceptive commentator seeking to make some sense of social and economic developments within most Southern countries today has no choice but to revisit, as it were, that classic on post-colonial societies, ‘The Wretched of the Earth’ by Frantz Fanon. Decades after the South’s initial decolonization experience this work by the Algerian political scientist of repute remains profoundly relevant.
The fact that the Algeria of today is seeking accountability from its former colonizer, France, for the injustices visited on it during the decades of colonial rule enhances the value and continuing topicality of Frantz’s thinking and findings. The fact that the majority of the people of most decolonized states are continuing to be disempowered and deprived of development should doubly underline the significance of ‘The Wretched of the Earth’ as a landmark in the discourse on Southern questions. The world would be erring badly if it dismisses this evergreen on decolonization and its pains as in any way outdated.
Developments in contemporary China help to throw into relief some of the internal ‘structural deficiencies’ that have come to characterize most Southern societies in current times. However, these and many more ‘structural faults’ came to the attention of the likes of Fanon decades back.
It is with considerable reservations on their truthfulness that a commentator would need to read reports from the US’ Office of the Director of National Intelligence (ODNI) on developments in China, but one cannot approach with the same skepticism revelations on China by well-known media institutions such as Bloomberg News.
While an ODNI report quoted in this newspaper on March 25th, 2025, elaborated on the vast wealth believed to have been amassed by China’s contemporary rulers and their families over the years, Bloomberg News in a more studied manner said in 2012, among other things, on the same subject that, ‘Xi’s extended family had amassed assets totaling approximately $376 million, encompassing investments in sectors like rare earth minerals and real estate. However, no direct links were established between these assets and Xi or his immediate family.’
Such processes that are said to have taken hold in China in post- Mao times in particular are more or less true of most former colonies of the South. A clear case in point is Sri Lanka. More than 75 years into ‘independence’ the latter is yet to bring to book those sections of its ruling class that have grown enormously rich on ill-gotten gains. It seems that, as matters stand, these sections would never be held accountable for their unbounded financial avarice.
The mentioned processes of exploitation of a country’s wealth, explain in considerable measure, the continuing underdevelopment of the South. However, Fanon foresaw all these ills and more about the South long ago. In ‘The Wretched of the Earth’ he speaks insightfully about the ruling classes of the decolonized world, who, having got into the boots of the departing colonizers, left no stone unturned to appropriate the wealth of their countries by devious means and thereby grow into the stratum described as ‘the stinking rich.’
This is another dimension to the process referred to as ‘the development of underdevelopment.’ The process could also be described as ‘How the Other Half Dies’. The latter is the title of another evergreen piece of research of the seventies on the South’s development debacles by reputed researcher Susan George.
Now that the Non-aligned Movement is receiving some attention locally it would be apt to revisit as it were these development debacles that are continuing to bedevil the South. Among other things, NAM emerged as a voice of the world’s poor. In fact in the seventies it was referred to as ‘The trade union of the poor.’ Accordingly, it had a strong developmental focus.
Besides the traditional aims of NAM, such as the need for the South to keep an ‘equidistance’ between the superpowers in the conduct of its affairs, the ruling strata of developing countries were also expected to deliver to their peoples equitable development. This was a foremost dimension in the liberation of the South. That is, economic growth needed to be accompanied by re-distributive justice. In the absence of these key conditions no development could be said to have occurred.
Basing ourselves on these yardsticks of development, it could be said that Southern rulers have failed their peoples right through these decades of decolonization. Those countries which have claimed to be socialistic or centrally planned should come in for the harshest criticism. Accordingly, a central aim of NAM has gone largely unachieved.
It does not follow from the foregoing that NAM has failed completely. It is just that those who have been charged with achieving NAM’s central aims have allowed the Movement to go into decline. All evidence points to the fact that they have allowed themselves to be carried away by the elusive charms of the market economy, which three decades ago, came to be favoured over central planning as an essential of development by the South’s ruling strata.
However, now with the returning to power in the US of Donald Trump and the political Right, the affairs of the South could, in a sense, be described as having come full circle. The downgrading of USAID, for instance, and the consequent scaling down of numerous forms of assistance to the South could be expected to aggravate the development ills of the hemisphere. For instance, the latter would need to brace for stepped-up unemployment, poverty and social discontent.
The South could be said to have arrived at a juncture where it would need to seek ways of collectively advancing its best interests once again with little or no dependence on external assistance. Now is the time for Southern organizations such as NAM to come to the forefront of the affairs of the South. Sheer necessity should compel the hemisphere to think and act collectively.
Accordingly, the possibility of South-South cooperation should be explored anew and the relevant institutional and policy framework needs to be created to take on the relevant challenges.
It is not the case that these challenges ceased to exist over the past few decades. Rather it is a case of these obligations being ignored by the South’s ruling strata in the belief that externally imposed solutions to the South’s development questions would prove successful. Besides, these classes were governed by self- interest.
It is pressure by the people that would enable their rulers to see the error of their ways. An obligation is cast on social democratic forces or the Centre-Left to come to center stage and take on this challenge of raising the political awareness of the people.
On the morning of 21 March, 2025, a Chinese-built K-8 jet trainer aircraft of the Sri Lanka Air Force (SLAF) crashed at Wariyapola. Fortunately, the two pilots ejected from the aircraft and parachuted down to safety.
A team of seven has been appointed to investigate the accident. Their task is to find the ‘cause behind the cause’, or the root cause. Ejecting from an aircraft usually has physical and psychological repercussions. The crew involved in the crash are the best witnesses, and they must be well rested and ready for the accident inquiry. It is vital that a non-punitive atmosphere must prevail. If the pilots believe that they are under threat of punishment, they will try to withhold vital information and not reveal the truth behind what happened, prompting their decision to abandon the stricken aircraft. In the interest of fairness, the crew must have a professional colleague to represent them at the Inquiry.
2000 years ago, the Roman philosopher Cicero said that “To err is human.” Alexander Pope said, “To err is human. To forgive, divine.” Yet in a Royal Air Force (RAF) hangar in the UK Force (RAF) hangs a sign declaring: “To err is human. To forgive is not RAF policy” These are the two extremes.
Over the years, behavioural scientists have observed that errors and intelligence are two sides of the same coin. In other words, an intelligent human being is liable to make errors. They went on to label these acts of omission and commission as ‘Slips, Lapses, Mistakes and Violations’.
To illustrate the point in a motoring context, if one was restricted to driving at a speed limit of 100 kph along an expressway and the speed crept up to 120 kph, then it is a ‘Slip’ on one’s part. If you forgot to fasten the seatbelt, it is a ‘Lapse’. While driving along a two-lane road, if a driver thinks in his/her judgement that the way is clear and tries to overtake slower traffic on the road, using the opposite lane, then encounters unanticipated opposite traffic and is forced to get back to the correct lane, that is a ‘Mistake’. Finally, if a double line is crossed while overtaking, while aware that the law is being broken, that is labelled as a ‘Violation’. In theory, all of the above could be applied to flying as well.
In the mid-Seventies, Elwyn Edwards and Frank Hawkins proposed that good interaction between Software (paperwork), Hardware (the aircraft and other machines), Liveware (human element) and the (working) environment are the essentials in safe flight operations. Labelled the ‘SHELL’ concept, it was adopted by the International Civil Aviation Organisation. (ICAO). (See Diagram 01)
In diagram 01, two ‘L’s depict the ‘Liveware’, inside and outside an aircraft flightdeck. The ‘L’ at the centre is the pilot in command (PIC), who should know his/her strengths and weaknesses, know the same of his/her crew, aircraft, and their mission, and, above all, be continuously evaluating the risks.
Finally, Prof. James Reason proposed the Swiss Cheese Theory of Accident Causation. (See Diagram 02)
From this diagram we see that built in defences in a system are like slices of Swiss cheese. There are pre-existing holes at random which, unfortunately, may align and allow the crew at the ‘sharp end’ to carry out a procedure unchecked.
Although it is easy and self-satisfying to blame a crew, or an individual, at an official accident investigation, what should be asked, instead, is why or how the system failed them? Furthermore, a ‘just culture’ must prevail.
The PIC and crew are the last line of defence in air safety and accident prevention. (See Diagram 3)
A daily newspaper reported that it is now left to be seen whether the crash on 21 March was due to mechanical failure or pilot error. Why is it that when a judge makes a wrong judgement it is termed ‘Miscarriage of Justice’ or when a Surgeon loses a patient on the operating table it is ‘Surgical Misadventure’, but when a pilot makes an honest error, it is called ‘Pilot Error’? I believe it should be termed ‘Human Condition’.
Even before the accident investigation had started, on 23 March, 2025, Minister of Civil Aviation, Bimal Ratnayake, went on record saying that the Ministry of Defence had told him the accident was due to an ‘athweradda’ (error). This kind of premature declaration is a definite ‘no-no’ and breach of protocol. The Minister should not be pre-empting the accident enquiry’s findings and commenting on a subject not under his purview. Everyone concerned should wait for the accident report from the SLAF expert panel before commenting.
God bless the PIC and crew!
– Ad Astrian
Yes, it’s happening tomorrow, Friday (28th), and Saturday (29th,) and what makes this scene extra special is that you don’t need to rush and pack your travelling bags and fork out a tidy sum for your airfare to Thailand.
The Thai Street Food Festival, taking place at Siam Nivasa, 43, Dr. CWW Kannangara Mawatha, Colombo 7, will not only give you a taste of Thai delicacies but also Thai culture, Thai music, and Thai dancing.
This event is being organised by the Thai Community, in Sri Lanka, in collaboration with the Royal Thai Embassy in Colombo.
The Thai Community has been very active and they make every effort to promote Amazing Thailand, to Sri Lankans, in every possible way they can.
Regarding the happening, taking place tomorrow, and on Saturday, they say they are thrilled to give Sri Lankans the vibrant Thai Street Food Festival.
Explaining how Thai souvenirs are turned out
I’m told that his event is part of a series of activities, put together by the Royal Thai Embassy, to commemorate 70 years of diplomatic relations between Thailand and Sri Lanka.
At the Thai Street Food Festival, starting at 5.00 pm., you could immerse yourself in lively Thai culture, savour delicious Thai dishes, prepared by Colombo’s top-notch restaurants, enjoy live music, captivate dance performances, and explore Thai Community members offering a feast of food and beverages … all connected with Amazing Thailand.
Some of the EXCO members of the Thai Community, in Sri Lanka,
with the Ambassador for Thailand
I’m sure most of my readers would have been to Thailand (I’ve been there 24 times) and experienced what Amazing Thailand has to offer visitors … cultural richness, culinary delights and unique experiences.
Well, if you haven’t been to Thailand, as yet, this is the opportunity for you to experience a little bit of Thailand … right here in Colombo; and for those who have experienced the real Thailand, the Thai Street Food Festival will bring back those happy times … all over again!
Remember, ENTRANCE IS FREE.
New education reforms are not only to align education with job market demands but also to cultivate skilled youth who can contribute to the economy and provide leadership to society -Prime Minister
Showers above 75 mm can be expected at some places in Sabaragamuwa, Southern and Uva provinces and Ampara district after 1pm
IPL 2025: KKR spinners stifle Royals before Quinton de Kock gets the job done
-
Business6 days agoCargoserv Shipping partners Prima Ceylon & onboards Nestlé Lanka for landmark rail logistics initiative
-
News4 days agoSeniors welcome three percent increase in deposit rates
-
Features4 days agoThe US, Israel, Palestine, and Mahmoud Khalil
-
Business6 days agoSri Lankans Vote Dialog as the Telecommunication Brand and Service Brand of the Year
-
News4 days agoScholarships for children of estate workers now open
-
News5 days agoDefence Ministry of Japan Delegation visits Pathfinder Foundation
-
Features6 days agoThe Vaping Veil: Unmasking the dangers of E-Cigarettes
-
News6 days ago‘Deshabandu is on SLC payroll’; Hesha tables documents