Iatrogenic - Possibility of Harm Through the Helping Process - Research Paper Example

? Introduction: Medical history continually reveals that unevaluated treatment, regardless of how sincerely administered, is at times useless and wasteful and in some cases even dangerous or harmful. According to Gordis (1987), the lessons we have learnt through history of medicine is that what is reasonable may be false and what is done earnestly may be useless or worse. Unintentional damage in the name of medical help is a persistent argument in today’s world. The possibility of harm through the helping process is illustrated in two medical terms: Iatrogenic illness (disease caused to the patient as a result of medical treatment) and Nosocomial illness (ailment acquired during the institutional treatment). The term Iatrogenic is defined as “induced in patient by physician’s actions, manner and therapy”. This term is specifically used to describe complications or adverse effects medical advice or treatment. Similarly, a pathological variation leading to detrimental consequences in a patient’s health caused by inappropriate practice of health care professionals is regarded as iatrogenic condition. According to WHO, iatrogenic disease may be defined as adverse drug reactions or complications induced by non drug medical interventions. Darchy et al., (1998) defined it, as a disease stimulated by drug prescribed by the doctor after a medical or surgical procedure. Health care associated or hospital acquired infections are a global problem. Iatrogenic frequently leads to severe complications and may require increased use of health care resources and medication, laboratory testing and prolonged duration of hospitalization. Health care personnel targets disease or risk factors for a future ailments by examining, diagnosing and prescribing a procedure for therapy. Most often, the objective of the caregiver is to prevent an ailment however, most of the effective therapies have side effects. Therefore, a dispute remains whether the benefits outweigh the harm. Initially, the focal point of iatrogenic infections is actions or inactions in terms of services of health care professionals such as physicians, pharmacists, therapists, nurses, psychologist etc. Also, the service environment of a hospital may be basis of iatrogenic (White, MA and Kleber, 2008). The estimated deaths caused by iatrogenic illness are 250,000 that make it third largest causes of deaths in U.S. (White, MA and Kleber, 2008). It costs about 6 billion pounds each year in United Kingdom for compensation (one tenth of NHS budget). History: Word iatrogenic is derived from “Iatros” a Greek word meaning brought forth by healer. Iatrogenic history can be traced back to 1800 s, when prior to implementation of aseptic techniques (hand washing and use of sterile gloves) thousands of women died due to puerperal fever; an infectious disease that was transferred between patients following delivery. Likewise, many soldiers that were injured in civil war died due to infections caused by health care personal in hospital tents. Later in 1847, Dr. Ignaz Semmelweis introduced the concept of hand washing prior to patient handling which dramatically dropped the rate of infections caused by physicians. In modern medical times, in the presence of several aseptic techniques the incidence of infection caused by health care professionals is considerably reduced however, still it is regarded as a major issue in medical science (Cina and Perper, 2010). Presentations: Iatrogenic harm caused from errors in diagnosis can be broadly divided into three types: false positive results (diagnosing a disease/disorder in a individual who does not have one), false negatives (mis-diagnosing a disease/disorder in an individual or misjudging the severity of a disease/disorder) and failure to respond and execute to a long term treatment or recovery in a disease. It is a result of procedures or therapeutic treatments or diagnostic examinations. Most of the iatrogenic conditions become clinically evident during the hospital stay however, the infections caused by pathogens having longer incubation periods such as hepatitis- B may exhibit clinical presentations later. Iatrogenic harm from treatment dosage and procedure can be a result of insufficient treatment practices such as low doses of antibiotics often results in a chronic condition of a disease, or excessive treatment (unnecessary medical procedures or higher doses) which increases the risks of side effects (individual and allergic reactions to medication) of a particular treatment. Some of the iatrogenic effects are obvious such as complications after surgery while others may be less apparent such as drug interactions, chronic pain conditions etc. Drug interaction is one of the most common iatrogenic conditions which are signified by any allergic reaction or toxicity to a specific drug. Drugs can be categorized as steroids, cytostatic, immuno-suppressive, antibiotic, and irradiation. Most common reported iatrogenic events include adverse drug reaction, disease caused by administration of vaccines, infections conveyed through blood transfusions, adverse effects of diagnostic tests (such as cancers induced by mammography or by estrogen replacement therapy in women to prevent heart diseases and osteoporosis) (Wiener, 1998). Other iatrogenic infections include urinary tract infections, respiratory and tissue infections (Fulmer, Foreman and Walker, 2001). These infections are a source of major concerns in medical field. Iatrogenic infections may be localized or systemic and can involve any system of the body (Riedinger and Robbins, 1998). Examples of iatrogenic infections are surgical site infections and UTIs as a result of catheterization of patients. It is important to note that not all the hospital acquired infections are iatrogenic (Engelkirk and Duben-Engelkirk, 2010). Severe iatrogenic events are defined as any unintended harm or complication which results in death, disability or extended hospital stay caused by health care management. Medication errors are the events that take place during the process of ordering, transcribing, dispensing, administering or monitoring of a drug (Ligi et al., 2008). Hospital acquired infections associated with medical care that manifest at 48 hours or later after admission. Statistics: Despite the emergence of modern medical techniques iatrogenic diseases continue to impact health and resources of a society. A study conducted by Institute of medicine (IOM) estimated 44,000 to 98,000 deaths per annum from medical errors. Even considering the lower estimates, more people die each year from medical errors than road accidents, breast cancer and AIDS. The empirical data of the modern medical system suggests iatrogenic as a serious problem. According to Wiener (1998), Harvard medical practice study group studied the sample of 30,000 hospital records from over 50 hospitals in New York State and found that one in eight patients suffered from iatrogenic fatalities out of 3.7% of hospitalization induced iatrogenic health events. Therefore, an average of annual total of 1.2 million iatrogenic injuries and over 150,000 iatrogenic deaths as result of hospitalization were estimated in U.S making it third largest cause of deaths. One of the major iatrogenic injuries includes adverse drug events (ADEs) which are characterized by allergic reactions, mis-prescribed drugs, drug-drug interaction. Earlier studies in 1970s suggested that ADEs account for about 140,000 deaths annually in U.S. Recent studies imply around 200,000-2,000,000 patients afflicted with ADEs each year. Nonetheless, these studies do not represent the full scope of impact of medical care on patients because only short term effects are accounted and long term injuries may become apparent after several years (Wiener, 1998). These are considered to be one of major source of iatrogenic illness and around 30% of hospitalized patients experience this condition. These reactions can be broadly classified into toxic and allergic reactions. Most of the drug reactions including specific side effects, drug interaction and over or under doses are toxic while only 6-10% is allergic reactions and are more serious and life threatening (Hillman, 2005). Stanzak (2006) reported a study in which the physician is unable to comprehend and treat the drug related reactions and allergies in 63% of the cases. Drug induced events are so critical in patient’s health that out of 28% emergency room drug related events, 25% are reported to be serious and life threatening. Adverse drug reaction is a key stone in recognizing potentially harmful drugs and drug-drug interaction however; most of the cases remain unreported by all levels of health care professionals (Stanzak, 2006). In a study conducted by Baune et al., (2003) on medical iatrogenesis in hospitalized older patients revealed that these infections are results of adverse drug related events and nosocomial infections. ADE s is linked to alterations in pharmaco-dynamics and pharmaco-kinetics that happens in aging patients however, nosocomial infections particularly urinary tract infections, pneumonia and diarrhea are highly preventable. Risk Factors: Certain characteristics are reported to be significantly associated with high rates of iatrogenic injury. These include patient’s age, lack of health insurance and hospital locality (Wiener, 1998). According to results of a study by McFarland (1995), incidence of iatrogenic diarrhea developed in 32.9% of general medicine patients and was more likely to develop in patients with gastrointestinal problems, renal conditions, recent surgery or antibiotic use. Incidence of iatrogenic conditions is 5-10 times higher in ICU rather than wards due to routine invasive techniques, use of urinary catheters, endo-tracheal tubes and ventilators. In a study exploring the risk factors of iatrogenic disease that elderly patients are at a higher risk of contacting such disease due to increased medical interventions leading to drug reactions or multiple chronic diseases. Drug induced iatrogenic disease is more pronounced in patients taking multiple prescription for chronic diseases and with low immunity i.e. malnourished, renal failure etc. Multiple chronic disease treatment increases the risk of iatrogenic illness e.g. treatment of arthritis with a non-steriodal anti-inflammatory drug may aggravate heart failure and chronic gastritis. Incidence: Incidence of iatrogenic disease is analyzed to be between 3.4 to 33.9%. In his study Darchy et al., (1998) reported that 68 patients (10.9%), were considered iatrogenic cases out of 623 patients admitted to intensive care Unit. Of 68 patients of iatrogenic disease, the causes were reported to be drug related in 41 cases, medical intervention in 12 and surgical intervention in 15. Studies of elderly patients in U.S suggest that more than 180,000 life threatening or fatal adverse drug reactions are encountered out of which half are considered preventable. The incidence of adverse drug events may be decreased to 57.9% that include therapeutic errors such as drug administration, drug-drug interactions and dosage errors (Permpongkosol, 2011). According to Permpongkosol (2011), 19.5% of intensive care unit admissions are due to iatrogenic events with clinical presentations of cardiac disease, hypertension, gastrointestinal complications etc. Causative factors: Inadequate patient evaluation, absence of follow up, irregular monitoring, failure to perform necessary tests is contributed to development of iatrogenic conditions. Also, under experimented or unproven medical procedures may cause iatrogenic. Several core sources of iatrogenic injury seem to be significant. At a first glance, probability of side effects of a particular treatment and physician’s partial knowledge of full effects of a therapy might play a role in iatrogenic illness. The revenue based structures of medicine manufacturing and development of devices and other medical equipment may also play a vital role in influencing iatrogenic causes. Another major iatrogenic source is crumbling system of medical care. Scarce information sharing among hospital doctors and departments may lead to several iatrogenic conditions such as adverse drug reactions (Wiener, 1998). Health care professional often harbor bacteria and other pathogens and may transfer dangerous infections to patients through clothing and contaminated scrubs. In a study conducted at New York Medical Center of Queens, samples of necktie from physicians were tested for pathogens. Half of these were carriers of bacteria causing pneumonia, skin infections, meningitis, sepsis, toxic shock syndrome etc. Similarly, physicians may also be carriers of hepatitis B and C viruses or HIV (Cina and Perper, 2010). Also, transmission of such viruses in iatrogenic disease is due to improper sterilization of medical and surgical equipment. One of the causative agents of iatrogenic disease is negligence to aseptic procedures by hospital staff and physicians. For example in surgical patients absence of aseptic introduction of catheter and proper sterile drainage and care of catheter increases the risks of urinary tract infections in patients. Similarly, lack of basic techniques such as hand washing, use of sterile gloves and disinfection of canula may contribute to iatrogenic infection. Also, patients in CCU on life support ventilators have an increased risk of ventilator associated pneumonia due to unhygienic suction techniques, aspirations etc. One of the bases for the origin of iatrogenic infections may be administration of bogus drugs or vaccines. Evidence based clinical trials is a part of prescribing drugs for approval. These clinical trials are designed according to the needs of sponsors and desired outcomes are produced by a system of fraudulent trial design, selective result reporting, statistical misinterpretation etc. In context of reproductive diseases, iatrogenic infections are majorly caused by introduction of microorganisms into reproductive tract through medical procedures such as induced abortion, insertion of IUD, menstrual regulations and during childbirth. These iatrogenic infections caused by unsterilized medical equipment could lead pelvic inflammatory disease and severe complications such as infertility, spontaneous abortions, pelvic abscesses and menstrual disturbance etc (Population Council, 2001). Very rare cases of iatrogenic illness may be caused by psychological or muscular diseases in physicians. Accidental errors contributed by sleep deprivation in long medical resident hours may worsen the situation. Preventions: Prevention of iatrogenic infections is critical in health care facilities as they increase the morbidity and mortality rates, increased duration of hospital stay, extra financial costs. Ligi et al., (2008), reported that 40-60% of iatrogenic events are preventable; however they are less preventable in neonates than in adults and children. Most common of these preventable iatrogenic among neonates were respiratory and drug events. In a specific study Baune at al., 2003 showed that ADE resulted in serious complications in 73% of the patients however, 25% of ADE could have been avoided. Identification of patients at high risk of contacting iatrogenic disease, minimization of prescription medicine, early diagnosis and treatment of illness and close monitoring of chronic diseases are vital in prevention of iatrogenic. According to Mercier et al., (2010) 73.8% of iatrogenic cases in intensive care unit in their study seemed preventable. Traditionally, iatrogenic disease prevention can be divided into primary, secondary and tertiary preventive measures; however, specific boundaries cannot be defined in such cases. Primary prevention intends to stop iatrogenic disease by reducing or eliminating its risk factors. Secondary prevention aims at early detection, diagnosis and treatment of iatrogenic conditions before functional losses occur thus decreasing the morbidity and mortality rate. Tertiary prevention focuses on management of chronic disease prior to further functional losses (Permpongkosol, 2011). Reducing the frequency and consequences of iatrogenic illness can be accomplished through series of approach. Improving the quality and accessibility to medical services and care, assuring the technical competence of health care providers may prove to be beneficial in this regard. Therefore the focus should be on education and training in medical institutions about the severity of iatrogenic illness. Also supervision of staff to follow sterile protocols may help (Population Council, 2001). Health care administrators such as physician director, nursing and infection control administrators, laboratory staff should review all the iatrogenic patient cases and focus on causes, identification and preventive measures in future. Education about iatrogenic diseases is an important issue that needs to be addressed. In this regard, staff refresher courses must be designed to educate about precautions of handling medical equipment and disinfection of work place. Hospital administration must realize the risks associated with iatrogenic infections and must device policies for strict adherence to standard precautions and elimination of hazardous wastes. In this regard, special monitoring teams may be formulated that scrutinize the actions of physicians and nurses. Prevention of iatrogenic illness may be achieved by proper sterilization of medical instruments, adherence to sterile protocols during examinations and surgical procedures such as hand washing, screening and treatment of pre-existing medical conditions and diseases before starting new treatments (Population Council, 2001). Malpractice law may also be significant in this respect. If the health care providers are answerable for administering a treatment that induces iatrogenic effects or in some cases failing to treat the target ailment are also important. Increased organization and management in hospital medical care may manifest less hospital acquired infections. In particular, information sharing among physicians for treatment of patient’s various ailments and latest computerized system will help to lower the rate of iatrogenic events (Wiener, 1998). Consideration for successful development, testing and execution of effective prevention policies in iatrogenic events is critical in modern medical practice. In this regard, incident reporting and research will not only help to monitor and prevent iatrogenic events but also provide educational advantages to medical care staff (Ligi et al., 2008). Specific interventions: Approximately 50% of iatrogenic cases are preventable if timely intervention is provided. Language barriers and disabilities should be addressed among patients especially elderly to reduce the risk of mis-diagnosis of disease. By application of simple precautionary measures such as increased acquaintance with contraindications, restriction to self-medication and decreasing the number of concomitant drugs can produce drastic decrease in iatrogenic illness (Permpongkosol, 2011). Improved team work and partnership among the physicians and pharmacologists can play a role in prevention and early detection of adverse drug reaction. Also, the physicians should analyze the drug regimen of patient twice a year and reassess the effects of drugs on patient’s health (Permpongkosol, 2011). Active participation on the part of pharmacists on patient’s prescription drugs such as pharmacokinetics consultation and general monitoring can also help to reduce adverse drug reactions (Zellmer, 2002). Rate of iatrogenic infections can be further reduced by assuring the use of disposal needles, syringes and medical and dental equipment. Drug companies are involved in creation and marketing of new drugs available for treatment of different diseases. However, often, these drug companies are involved in business that can adversely affect patient’s health. This includes introduction of new expensive drugs, vaccines with low approval from clinical trials, marketing strategies aiming at confusing the potential patient etc. (Stanzak, 2006). Iatrogenic illness rate can be minimized by implementation of following practices: Strict licensure and certification standards that emphasize safety and professional practice protocols for physicians and hospitals may reduce the rate of iatrogenic. These include hand washing, use of sterile gloves etc. Clinical supervision by highly skilled physicians for quick intervention to a detrioting clinical condition and later documentation of that particular condition for future referencing (White, MA and Kleber, 2008). Mandatory training and continued education for all the health care professionals for awareness, prevention and treatment of iatrogenic injuries. Health care givers specifically physicians and pharmacists must realize the variability of reactions (optimal reactions, partial reactions, non-response and adverse reactions) to all the treatments (White, MA and Kleber, 2008). Immunization to major chronic transmittable diseases should be ensured in all health care professionals. Commitment of health care personals to evidence based treatment practices. Drug companies and Food and drug Administration should involve physicians, nurses and pharmacists in drug approval, labeling and packaging of drugs (Zellmer, 2002). Close monitoring of all drug related activities and past histories of drug reactions and use should be analyzed in detail. References Baune, B., Kessler, V., Patris, S., Descamps, V., Casalino, E., Quenon JL. and Farinotti, R. (2003). Medicinal iatrogenics in hospitals: A survey on a given day. Presse Med. Vol. 32(15):683-688. Cina, S. and Perper, J. (2010). When doctors kill. Springer. 187-188. 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