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dr. Widi Antono Sp. B, Mkes , Dr. dr. Cahyono Hadi S.H.

Sp.OG (K)
§ Advances in technology have a
tremendous impact on all
aspects of life
§ Patient’scomplains are almost
seen all the time in
conventional media such as
newspapers, television, social
media
§ Doctors have been equipped with required competencies and
complex licensing yet still faces the risk of demands from patients or
patients family both material and criminal threats
§ Those threats
comes from treatment process, treatment outcome
down to diagnostic process
§ PABI needs to formulate concrete steps to protect its
members
§ Patient’s identity:
§ Hospital : Type C, Margoyoso, Pati
§ Name : DA
§ Gender : Female
§ Age : 15 years old
§ Address : Tegal Arum, Margoyoso, Pati
§ Marital Status : Not married
§ Administrated date : January 4, 2015
§A 15-year-old female came to the ER
with abdominal pain felt throughout
the abdominal field. The pain was felt
for more or less 3 days, initially in the
lower right quadrant which increases
within the last 1 day and felt throughout
the abdominal field. Patient was
feverish, nausea and vomiting with a
regurgitant characteristic. Patient was
not able to pass stool for the last 3 days,
urination was normal. History of
menstrual delay is denied. History of
previous diseases are denied.
• General condition : Looks ill • Abdomen :
• Inspection : distended, darm
• Awareness : Compos mentis contour and darm steifung (-)
• Auscultation : decreased bowel
• Blood pressure : 140/90mmHg sound
• Heart rate : 90x/minute • Percussion : tympany, dull upon
liver percussion (+), shifting
dullness(+)
• Temperature : 39,2oC • Palpation : tenderness (+) within
• Respiratory rate : 20x/minute the abdominal field, punctum
maximum on the right lower
• Head : anemic conjunctiva quadrant, muscular defense (+)
• External genital : within normal
• Thorax : heart and lungs are range
within normal range • Extremity : within normal range
§ Hb : 11,0 mg/dL
§ Leukocyte : 14.900
§ Glucose , SGOT, SGPT, ureum, creatinine, electrolyte
are within normal range
Emergency Ward
Plan :
laparotomy
Room

• Patient was • reassessment • Consultation


diagnosed was done by a was done with
with acute surgeon and an anesthetic
appendicitis was doctor
diagnosed
generalized
peritonitis ec
perforated
appendicitis
Operation Consultation Operation
with Sp. OG was ended

• Active • Suspicion • To prevent


bleeding of an further
+ brownish obstetrics damage
mass case because
the source
of the
bleeding
can not yet
be
identified
§ Patient
was referred to Kariadi Hospital in Semarang accompanied
by 2 nurses.
§ CT Scan showed rupture of a torsion ovarian cyst
§ After improvementof the patient’s general condition for
approximately 2 weeks and meetings, patient was planned for
laparatomy
1. The reason the patient is reffered

2. The absence of any investigation prior


to the operation

3. The outcome of the surgery does not


match the initial diagnosis

4. Transfusion done late

5. The occurence of disfigurement of the


body in the form of surgical wounds
The patient’s family contacted to non-governmental organization
(LSM) and they want the case to be acted upon by law and
appoints LSM as a legal representative. LSM then make a letter
addressed to the hospital and continued the district health office
(Dinas Kabupaten Kesehatan)

Witnessed by IDI branch of Pati then conducted meeting


between district health office with surgeon and hospital
side.

The contents of the letters are malpractices that cause


patient dissatisfaction
After in-depth discussion, viewed from various aspects ranging from
anamnesis, physical examination, diagnosis, treatment in hospital ward,
preparation of operation, surgery to referral to the Hospital of Kariadi
Semarang, has been concluded that there is no discrepancy and violation of
law and medical ethics.

The result of the meeting decides to no follow-up from the case and the case is
considered complete.
But it turns out the patient’s family did not satisfied, they are still reporting to
DPRD and print media and asking for compensation up to hundreds of million of
rupiah to the surgeon and the hospital. The surgeon and the hospital do not
responding and coordinating with the insurance of the profession, called
BUMIDA.

The result of the meeting concluded and suggested the hospital to


approach informally with the family.

The family came to an agreement with the hospital with an amount of


ten million rupiah
§ Patient doctor relationships are bound in a therapy contract
§ The therapy contractis an agreement between doctor and patient, in
which both of you have rights and responsibilities, that is subjected to
the civil law.
§ Legal bond is a commitment between two or more legal subjects to do
or not to do something and to give called achievement something
(article 1313 juncto article 1234 BW) .
• Medical administration legal terms : letter of registration (STR) and license of practice
(SIP)
• Articel 75 and 76 of Law number 29 of 2004
• Does not have STR and SIP = violation of administrative law
- Potentially leading to medical malpractice
The obligation to keep
everything secret about
the patient (Article16)

Three obligations of doctors in


The obligation to give
KODEKI are contained in Law
emergency treatment
number 29 of 2004 and is a
(Article 17)
crime (Article 79 juncto 51)

The obligation to refer


patients to a more skilled
and capable physician
(Article 14).
§ Article 50 of Law number 29 of 2004 mentioned the limited rights of physicians
:
a.Obtain legal protection throughout the course of carrying out the
duties in accordance with Professional Standards and Standards of
Operational Procedures
b. Provide medical services according to professional standards
and Standards of Operational Procedures

c. Obtain complete and honest information from patients or their


family

d. Receive service rewards


The patient’s obligations are set out in Article 53 number 29 of 2004, which
consists of :

1. Obligation to obtain complete and honest information about their


health
2. Obligation to obey the advice and instructions of the doctor or
dentist
3. Obligation to comply with the provisions applicable in health care
facilities
4. Provide compensation for services received
The right of the patient specified in Article 52 is as follows :

1. To get the fully information about medical treatment as described in


the Article 45 paragraph (3)
2. Ask the opinion of a doctor or other dentist
3. To get service according to medical needs
4. Reject medical treatment, and
5. To get the contents of medical record
Violation of the patient’s
obligations may serve as a reason
for the doctor’s defense when the
breach of the obligation leads to
misdiagnosis and mistreatment
§ In the above case (children 15 years old with peritonitis) the doctor has done his
duties

Article 58 paragraph (1) of Law No.36 of 2014, is to give medical service in


accordance with Professional Standards, Standards of Operational Procedure and
professional ethics and health needs of health care recipients.

§ Perhaps the controversy is whether there is still a need more investigation despite
clear clinical signs of peritonitis.
Viewed from therapeutic contracts, then in this case :
• The doctor has done the duties
• The patient’s obligation to give honest
information about the health is not fulfilled.
§ Patient’s
right to get the right medical treatment that has been pointed
out in point no 3
§ Permenkes No. 585/ Menkes/ PER/ IX/ 1989 dan penjelasan pasal
45 UU No 29 tahun 2004 it is said that approval is given by an adult who
is in fully aware and mentally healthy (Article 8.1).
§ Precisely thisis detrimental to the patient because the permenkes has
led to patients not getting proper health care.
§ Although legally this
may be justified. It should be included in the clause
on the need for more than one family consent in order to make important
decisions about action to the child that can be more accountable.
§ So the health status of children is not a monopoly of one person only.
According to dr. Gatot Suharto SH,Sp.F,Mkes, legal action is mapped into several degree

1st degree : Legal


notice

2nd degree : Report

3rd degree : Investigation

4th degree : Trial


§ Doctors have to understand the mapping of medicolegal to
anticipate future problems that may arise

1. Why patient required to be referred?

2. Why further clinical examination aren’t being conducted


prior to operation?

3. Why is the outcome of surgery does not match the initial


diagnosis?

4. Why transfusions are given too late?

5. Whether the scar obtained from the operation is


subjected as a criminal law?
§ Why patient required to be referred? Permenkes No.001 tahun 2012 article 9

Referrer is not able to give health services according to the needs of


patient as to the limited facility, equipment and/or resources

§ Doctors have to subject to Law No.36 year 2014 article 58 paragraph 1e which is to
referr recipients of health services to a health facility with higher competance and
compatible
§ To answer the question Why further investigations aren’t being conducted prior to
operation? :

In peritonitis caused by appendicitis, according to “Pedoman Pelayanan


Medik Dokter Spesialis Bedah Umum Indonesia” 2nd edition year 2006
the recommended clinical examination is USG

§ Surgery literature shows USG have a sensitivity of 85% and specificity of 90%. In
patients with unspecific clinical presentation abdominal CT-scan is recommended
§Patients family and lawyer used these points to
pressure surgeons and the hospital.
§Law No.44 year 2009 law 29 paragraph (1)s :
hospitals have the obligation to protect and provide
legal assistance for all hospital personnels in
performing their duties
§Article 46 : hospitals have legally liable for all
losses incurred by the negligence of health
personnel in the hospital.
§Article 30 paragraph (1)e : hospital have the rights
to sue the party which causes loss to the hospital.
§ To understand Why is the outcome of surgery does not
match the initial diagnosis? it is necessary to understand
that medical science is not exact science.
§ Symptoms and signs of a similar disease do not always provide
the same diagnosis
§ According to M.Y.P. Ardianingtyas, S.H., LL.M dan Dr.
Charles M. Tampubulon even if doctor misdiagnosed ,the
doctor's actions can not be categorized as medical malpractice
/ medical neglect as long as the physician performs a medical
action against the patient Health Law, Indonesian Medical
Code of Ethics (KODEKI) and Standard of Medical
Profesion
§ Why transfusions are given too late, families assumed that blood
giving during the trip to Semarang was a delay that endangers the
patient.
In fact patient is in a stable hemodinamic state until the
arrival to the referral hospital

§ Complaints of defects in the patient's body is the most vulnerable


legally to be accused of malpractice

§ Until now to measure a medical treatment from a criminal law


standpoint because Culpa has entered into a medical malpractice
conventionally still refers to articles 359 and 360 Criminal Code

Article 360 paragraph (1): "... because of his mistake (his


negligence) caused others to get seriously injured .." Paragraph
(2): "... because of his error (negligence) causes others to be
injured in such a way as to cause an illness or obstruction to
perform a job or occupation for a certain period of time ..."
§ the legal liability that was demanded was a defect of an abdominal operative injury
that the plaintiff had said to be a lifelong affliction.

§ Many scholars argue that the necessary action in medical malpractice is inner Culpa
(Negligence)
§ Munir Fuadi details the results of malpractice in medicine are pain, injury,
disability, death, damage to the body, and soul or other loss to the patient in his
care
§ This result is at the same time an element of a crime (in criminal malpractice) or an
element of unlawful acts
§ Legal adage says in all types of surgery the operator's physician always hurts the
patient by inflicting injury on the patient which if not due to the law order then the
doctor may be subject to criminal sanction of the persecution.
§ In these patients, the wound is caused by the doctor's efforts to provide relief
§ So, doctors implements article 58 paragraph (1) Law No.36 Year 2014 letter (a) that
is providing health services in accordance with professional standards
§ Wound definition according to Criminal Code article 360 :
a. Severe injury paragraph (1)
b. Wound that causes illness paragraph (2)
c. Wound that causes the limitation to work during a certain
of time paragraph (2)
§ STR and SIP in accordance with Articles 75 and 76 of Law No.29
of 2004 on Medical Practice is a requirement of administrative
law, medical administration violation is one of the places where
the illegal nature of medical malpractice which has criminal
law consequences
§ The levels of medicolegal disputes can be mapped to a (I),
reporting (II), investigation (III), and court (IV)
§ Mistakes of diagnosis can not necessarily make a criminal case
as long as the physician performs a medical action against his
or her compliance with the Health Act, the Indonesian Medical
Code of Ethics (KODEKI)
§ The right of parents to refuse approval of the operation
is contrary to the right of the child to obtain the
necessary health services
§ Although there is no serious injury as mentioned in
Article 360 of the Criminal Code, the complainants
continue to question it. Doctors implement Article 58
paragraph (1) of Law No.36 Year 2004 letter (a) that is to
provide health services according to professional
standards, standard operational procedures, and
professional ethics and health needs of recipients of
health services
§ 1. Every doctor should have STR and SIP in place of
practice in order to avoid the risk of criminal law.
§ 2. Medicolegal levels should be completed at the
lowest level by means of good mediation. The mediator
in this case is the legal and social part of the hospital or
legal counsel of the professional insurance or
professional organization.
§ 3. establishing a diagnosis of generalized peritonitis
should perform attention to surgical clinical manual by
performing minimal abdominal ultrasound
examination or abdominal x-ray
§ 4. Thereshould be a rule of law that requires for the approval of
medical action carried out by not only the child's parent but
there must be a sufficiently knowledgeable companion.
Education about illness and medical action should be detailed to
make sure the family understands the diagnosis, medical
action, and prognosis of the disease.
§ 5.
Professional organizations (PABI) shall cooperate with a wide
range of legal institutions to protect their members throughout
Indonesia
§ 6. PABIneeds to refer to surgical clinical guidelines as standard
operating procedure in the field of general surgical science.