Bamsoet Examines Dissertation on Malpractice and Misdiagnosis
Bambang Soesuityo (Bamsoet), a member of the Indonesian House of Representatives from the Golkar Party, is pushing for a comprehensive strengthening of medico-legal services in hospitals. This is to ensure that patients who suffer losses due to alleged inaccurate diagnoses obtain legal certainty, protection, and justice. The issue of diagnosis cannot be viewed solely as an individual relationship between doctor and patient, as the diagnostic process occurs within a system involving doctors, nurses, laboratories, radiology, pharmacy, medical records, information technology, hospital management, as well as referral and clinical supervision mechanisms.
Therefore, when an alleged misdiagnosis occurs, hospitals must be able to ascertain exactly what happened, who is responsible, whether negligence occurred, and how the patient can achieve recovery.
The urgency for such strengthening is heightened because misdiagnosis is a globally recognised patient safety issue. The World Health Organization (WHO) estimates that misdiagnosis occurs in approximately 5-20 per cent of doctor-patient interactions and can manifest as delayed, missed, or incorrect diagnoses, or a failure to communicate a diagnosis properly.
WHO also places improving diagnostic safety as a vital part of the global patient safety agenda. On 17 September 2026, WHO will once again hold World Patient Safety Day, themed around safety in services for non-communicable diseases.
“Inaccurate diagnosis must be viewed objectively and carefully. A diagnosis that subsequently changes does not automatically imply malpractice, as the medical world operates under conditions of uncertainty and based on the clinical information available at the time of examination,” Bamsoet stated in his remarks on Monday (14/9/2026).
“However, if an error occurs because proper examinations were ignored, warning signs were disregarded, test results were not followed up, referrals were delayed, or professional and service standards were not met, then the matter must be seriously investigated from disciplinary, civil, administrative, and even criminal perspectives, provided the criminal elements are met,” he continued.
He expressed this while examining and serving as a co-promoter for the dissertation proposal defence of a doctoral student in law at Borobudur University, Kombes Pol. dr. Rommy Sebastian, titled “Formulation of Medico-Legal Services in Hospitals for Patients as Victims of Malpractice due to Inaccurate Diagnosis for Legal Certainty and Justice.” Other examiners present included Faisal, Ahmad Redi, and Tina Amelia.
He explained that one of the most important instruments in building legal certainty is medical records. In cases of alleged misdiagnosis, medical records must be able to explain the patient’s clinical journey in full, starting from initial complaints, physical examinations, working diagnoses, differential diagnoses, supporting tests, laboratory and radiology results, medication administration, medical procedures, communication with the patient, consultations, referrals, to the progression of the patient’s condition.
Consequently, the integrity and completeness of medical records must be a serious priority for hospitals.
“Medical records should not be treated merely as hospital administrative documents. Medical records are a vital part of patient safety and an instrument of evidence when disputes arise. If an alleged misdiagnosis occurs, it must be possible to trace what the doctor knew at that time, what examinations were performed, what results were available, what decisions were made, and why those decisions were made. In this way, the law can assess the process objectively, rather than solely relying on the final outcome,” said Bamsoet.
Bamsoet explained that hospitals need to strengthen diagnostic audit systems and functionally independent clinical reviews. Every serious incident, such as a delay in diagnosing a critical illness, medical actions that are inappropriate due to erroneous clinical information, or patients experiencing deterioration after receiving several services with the same diagnosis, needs to be evaluated systematically.
Such evaluations must seek the root cause, whether it stems from individual competence, communication between healthcare workers, laboratory errors, radiology delays, referral system failures, workload, weak standard operating procedures (SOP), or a combination of various factors.
“Do not build a hospital culture where every time an incident occurs, the immediate reaction is to find someone to blame. What must be sought first is the root cause. If a doctor is negligent, there must be accountability. If the laboratory is at fault, the radiology system is problematic, inter-unit communication fails, or hospital management fails to provide necessary facilities, then responsibility must be traced according to their respective portions. This approach is both fairer and more effective in preventing the same incidents from recurring,” said Bamsoet.
He noted that hospital medico-legal services should ideally not only act when a patient has already filed a lawsuit. Medico-legal services should be part of hospital governance from the moment an incident potentially harming a patient arises.
Hospitals need to have a mechanism that connects the medical committee, patient safety team, legal unit, risk management, relevant professionals, and patient complaint mechanisms. With such a mechanism, issues can be investigated earlier and not escalate into prolonged conflicts due to patients feeling they have not received an explanation.
“Medico-legal services should not be understood as a unit whose task is merely to face a patient’s lawyer or defend the hospital when a lawsuit occurs. The function of medico-legal services must be expanded into a system of prevention, investigation, resolution, and learning. When an alleged misdiagnosis occurs, patients must receive an adequate explanation, and the hospital must conduct an objective internal investigation, ensuring medical evidence is maintained with integrity.”