從病患觀點探討引起醫療糾紛產生的原因與類型--以台灣法院判決資料為基礎

Abstract

醫病爭議的最後仲裁處在法院，本研究目的乃為藉內容分析法解析法院之醫療糾紛判決文中所記載之發生糾紛之基礎資料、治療行為資料、醫療鑑定結果，來瞭解台灣發生醫療糾紛的趨勢、醫療疏失類型、醫療鑑定之疏失認定比率，進而分析其趨勢、疏失類型、疏失認定率，在台灣北、中、南區，與在各科別之間、各醫療機構層級間之差異性。 本研究利用「醫療糾紛、醫療過失、醫療疏失、醫療傷害、醫療損害」等五個全文檢索詞，搜尋司法院網站自民國88年8月1日至94年9月30日，所公布之民事之各地方法院之有關醫療糾紛判決文，而將其中非屬或重複醫療糾紛的判決文予以剔除，共取得162篇純屬醫療糾紛的判決為研究範圍。 研究步驟上乃以內容分析法解析判決書內容取得三個資料群：基礎資料群、治療行為資料群、醫療鑑定資料群，並以區域劃分、科別屬性、醫療機構層級分析三組資料群於其間的差異性，而得到下列之研究結果： 壹、台灣醫療糾紛起訴於法院之量的趨勢上並無持續上升之趨勢 由162件醫療糾紛民事判決分析，民國90年之起訴案件為33件達到最高峰，其後是下滑而非持續上升走勢。 貳、醫療糾紛的發生數量主要在內科系與外科系上，或屬醫學中心之層級 外科系與內科系發生糾紛之數量最多，共佔63.3％；而層級下以醫學中心佔32.7％最多。 參、引動起訴的醫療糾紛之主要疏失之型態為手術類、告知類、處置類、診斷類、用藥類等五類疏失型態 這五類疏失型態，共佔162件判決疏失總數718件之61.1％，乃為疏失之主要型態。 肆、162件醫療糾紛案件之不作為疏失型態，以檢查、轉院（診）、檢驗、診視等類為主要型態 不作為疏失常為醫院管理者或醫療照護提供者所無法自行發現的疏失型態，因其未有實質之行為，自然無法予以適當評價而仍有所更正或管理，本研究探勘不作為疏失數共有173件，佔疏失總數718件之24.1％。 伍、法院尋求醫療專業機構之諮詢次數過高，病患勝訴率與醫療鑑定疏失認定率略呈偏低 醫療糾紛162件案件之法院專業諮詢有343次，平均每一案件2.12次，認定疏失率為13.4％，法院判決之病患勝訴率為22.2％；其中「鑑定模式」則每件平均鑑定數為1.7次，認定疏失比率只有15.2％，過低之疏失認定率將造成鑑定次數的增加，其主因於病患方不相信鑑定結果而一再要求法院送往鑑定單位鑑定。 陸、台灣醫療糾紛判決之病患勝訴率以其所控訴之醫療機構屬南區、外科系、診所層級時之勝算機會高，且疏失率、勝訴率與醫療機層級略呈反向走勢 台灣162件醫療訴訟之病患方勝訴率在南區為27.3％，在外科系為26.1％，在診所層級更高達34.4％，均高出台灣整體平均之22.2％甚多；略以疾病嚴重度分醫療機構層級為兩級：醫學中心與區域醫院、地區醫院與診所，其勝訴率為17.3％對29.0％，其疏失認定率為13.3％對43.5％，兩者均差距甚大。 根據以上結果，本研究提出下列三項建議： 壹、對後續研究者之建議 從總病患數至醫療不良事件比率，在至醫療錯誤比、醫療過失比，再到過失案件之起訴比例、可獲補償的比例，於哈佛研究中訂出依序兩兩間的關係為：3.7%、27.6%、13.2%、約50%；本研究雖已探勘出起訴於法院之案件（162件），但要外推台灣醫療院所發生醫療不良事件實際情形，應留待後續研究者之研究。 貳、對醫院管理者之建議 不作為疏失乃反應醫療照護接受者對醫療照護提供者所提供之照護行為的積極性要求，且其常為醫院管理者或醫療照護提供者所無法自行發現的疏失型態，因其未有實質之行為，無法自行反省整段醫療行為的缺洞而能予以評價並加以管理。因此，醫院管理者可藉由本篇之不作為疏失類型及其對科系發生的頻率，針對特定科系、特定醫療行為予以監督與管理，以助品質提升。 參、對醫療鑑定單位的建議 同一案件重複鑑定的比例過高反應出民眾對專業醫療鑑定單位的不信任，加上鑑定疏失率的偏低（15.2％）更加重此種不信任的疑慮，因而一再請求法院重複鑑定。醫療鑑定機構如何讓民眾相信其鑑定結果是可信任的，其鑑定專業性是足夠的，其鑑定獨立性與公平性是不容質疑的，實令專業醫療鑑定機構仔細思量。

The final decisions of the arguments of the medical malpractices are at the justice hand of the Courts. The purpose of this study is based on the decisions of the Courts, including the preliminary information, medical treatment, and the results of medical judgments, to analyze the contents of the decisions and to investigate the trends and types of medical malpractice, and the ratio of the determined negligence in medical judgments. Furthermore, it analyzes the differences of the above data between the individual department of different level of hospitals in North, Middle and South Districts in Taiwan. This study uses five characteristic index including medical malpractice, medical error, medical negligence, medical injury and medical damage to surf all the decisions related to medical malpractice of the civil sues in District Courts from Aug. 1, 1999 to Sept. 30, 2005 and select 162 decisions which are decisions of pure medical malpractices screened from among decisions of non-malpractices or duplicated malpractices. The method of the study is by means of the “content analysis” to get three databases: preliminary information, medical treatment and medical judgments and to analyze the differences between these three databases. The results are as follows: 1. The trend of medical malpractice in Taiwan is not mounting. From the analysis of 162 civil decisions, the apex of the trend is in 2001 (30 cases) and it goes down rather than up thereafter. 2. Most of malpractices occur in the medicine and surgery departments, and in medical centers. There are 63.3% and 32.7%, respectively. 3. The major types to evoke sue are the procedures of surgery, pre-treatment notification, diagnosis, medical management and prescription. Theses five types are the major types of negligence and account for 61.1% (162/817 practices). 4. The types of omission errors are medical examinations, transfers, laboratory examinations and inspections. The omission errors are the types of negligence that the executives of hospitals or care-givers can’t notice by themselves. In regard of no actual misdoings, it is naturally difficult to give appropriate judgment for correction or management. In this study, there are totally 173 practices, accounting for 24.1% (173/817 practices). 5. There is relatively high rate that the Courts request for professional medical consultations and relatively low rates both of win for patients and the decisive judgment for medical negligence. There are total 343 professional consultations in 162 cases with average 2.12 times each case and the rate of negligence is 13.4%. The rate of win for patients is 22.2%. Among “judgment model” there is 1.7 times each case asked for judgment and the rate of decisive judgment for negligence is only 15.2%. Too low rate of recognition for negligence will increase the frequency for medical judgments and the main reason for this phenomenon is that the patients doubt the result and request for repeated judgments. 6. The rate of win for patients in malpractice decisions is higher in southern hospitals, in surgery department and in clinic level and there is a reverse relationship between the level of hospitals and the rates of the decisions for negligence and win. The rate of win for patients in southern hospitals is 27.3% in 162 cases and 26.1% in surgery department and 34.4 % in clinic level and they are much higher than the average rate 22.2% in Taiwan. According to the severity of diseases, the hospitals are separated into two categories: medical centers and district hospitals versus local hospitals and clinics. The rate of win and rate of decisions for negligence are 17.3% versus 29.0% and 13.3% versus 43.5%, respectively. There shows significant difference. According to the results, we propose three suggestions: 1. For future study In Harvard study, there are in-between relationships of the rates of total number of patients versus medical adverse events, versus medical malpractice , versus sue, and versus compensation: 3.7%, 27.6%, 13.2% and 50%, respectively. Although there are 162 cases analyzed in this study, the actual details of medical adverse events need further investigation. 2. For executives of hospitals Omission errors reflect the aggressive demand for the care-receivers to the care-givers and they often occur due to the negligence of executives or care-givers. Because there is no actual mistreatment, it is unable to be inspected along the whole medical treatment and, therefore, is difficult to evaluate and control. Hence, the executives can make more effort on inspection and control of the proposed types of omission errors, rates, specific field and treatment to promote the quality of medical care. 3. For faculty of medical judgment institution The relatively high rate of repeated judgments reflects the unbelief to the professional institute. The relatively low rate of negligence worsens the doubt and raises the rate of repeated judgments. The issues that how to convince the people medical judgment the professional institute made, how to provide adequate profession and how to represent its undoubted independence and justice need thorough considerations.