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2009 January - Note 1

Separate files / Case papers for mother and baby – A healthy practice for maternity homes - Dr. Piyush Prabhat, MD (Gynecology)

The purpose of law is to make society civilized and safer. In medicine, law aims to make doctors accountable for their acts. This is nothing but an effort to make medicine safer. But this burden should not be left to the courts or legislature only. The society, its members, and all concerned must also make their contribution in this process.

In case of medicine, it is imperative for the medical community to learn from mistakes and errors that have been committed to evolve new rules, regulations, and protocols. The aim of any such exercise should be to avoid or minimize such mistakes and errors. This will not only make medicine safer but also reduce the risk of medicolegal litigation faced by doctors.

In the case of G. Balakrishna Pai & Anr. v/s Sree Narayana Medical Mission General Hospital and T. B. Clinic & Ors. (reported in July issue, page No. a94/j291 ), decided by the National Consumer Disputes Redressal Commission, a very important shortcoming prevalent among hospitals and maternity homes has come to light.

Dr. Bhalchandran, who was the duty doctor present during delivery and was also sued by the patient had stated in the witness-box:

Q. It is recorded in the ‘Nurses Daily Record’ that injection Methergin, injection Betnesol is given at 9.55?
A.  “That also recorded time wrongly. I have not given instruction for Betnesol. Methergin is to contract the uterus after delivery. The case details of the baby is written through mother’s case sheet. Betnesol is given to the baby. Injection Methergin is to be given when the placenta expels.” (paragraph 29)

On reading the entire judgment it becomes clear that the case details of both mother and baby were written on the same sheet. The court after perusing the medical records came to the conclusion that both Betnesol and Methergin were given to the mother and made observations against the doctors.

The aforesaid can be explained in two ways. Betnesol was given to the baby and Methergin to the mother but the duty nurse had recorded this fact wrongly or because both the directions were written on the same page, the nurse may have erred and actually given both the medicines to the mother.

Thus, the first possibility is that though medication was right but this fact was recorded wrongly. Courts are slaves of evidence. Hence, no amount of pleading or justification could have saved the doctors as written evidence was against the doctors. In the eyes of law negligence is proved.

In the second case, which is undoubtedly a case of clinical negligence, the chances of error increased, obviously due to the fact there was a single case sheet for both mother and child.

In both the aforesaid eventualities, if the medical records of both the child and the mother were prepared separately, chances of errors or mistakes would have reduced considerably. Moreover, it would also be very helpful in cases where the child or the mother has to be shifted to another facility for further treatment. Instead of writing the entire case history, a copy of separate case sheets can be sent with the patient.

Hence, it would be advisable to keep separate file or case sheets of mother and neonate.


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