The domino effect
Hospital Doctor
Published on Wednesday March 21, 2001
Medical mistakes will always happen, writes Chris Alden – the question is what doctors do about them
It was a simple procedure, using a simple piece of equipment, and the consultant anaesthetist had performed it a thousand times before. But this had been a particularly busy week. He was tired. He was preoccupied. He was even carrying a bit of flu. So he checked he was doing the job correctly – double-checked – and, satisfied that he was, proceeded to squeeze the trigger in his hand.
It was shortly afterwards that Dr Willy Notcutt, of the James Paget Hospital, Norfolk, realised he had injected gallons of petrol into his diesel car.
In the same month, a doctor in Newham, east London, allegedly made a similar mistake. Similar in form, that is, but much graver in consequence.
Through a combination of events that is not yet fully known, nitrous oxide instead of oxygen was given to three-year-old Najiyah Hussain. Najiyah died.
The doctor involved was suspended and questioned by police under criminal caution. Coming as it did after a series of high-profile errors, including two incidents of the intrathecal injection of vincristine, the incident gave the national press another field day. Doctors simply wondered: ‘there but for the grace of God go I’.
We are human: we do things we do not intend to do. This month a pilot study in the BMJ by Vincent et al found that two British acute hospitals experienced an ‘adverse event’ – defined as ‘unintended injuries caused by medical management’ – in 11.7 per cent of procedures and 10.8 per cent of patients. About half of these events were judged, retrospectively, as ‘preventable with ordinary standards of care’. But although the research specifically refers to adverse events rather than medical error, doctors fear that the NHS hierarchy is blind to the distinction. The culture of creating a scapegoat is hard to shake.
Dr Peter Tomlin, secretary of the suspensions study group of the Society of Clinical Psychiatrists, says one problem is the lack of objective data – not just about errors, but also about the normal expectations of adverse outcomes.
He says: ‘In our experience, hospital managers have no idea what constitutes a medical mistake versus what is a normal, natural complication. We have had a number of cases where the hospital has made the allegation that because this patient suffered a major pulmonary embolus, that surgeon was incompetent – where in fact it is a risk.’
Managers can also fail to understand that, despite the profession’s best efforts and with the best will in the world, errors will continue to occur. Dr Allan Cole, medical director and consultant anaesthetist at the University Hospitals of Leicester, told Hospital Doctor about a ‘moderately serious’ drug error which occurred in his hospital’s paediatric intensive care unit.
‘When it was looked into, it turned out there were about 20 errors a month on that intensive care unit which were being reported – drug errors that were potentially quite serious, but none of the seriousness of the outcome which had brought it to our attention. Now there were very senior people within the organisation who said “20 incidents a month? We should close the unit down”.
‘I looked into this further. We worked out the drug manoeuvres that could potentially go wrong on that intensive care unit every month: about 20,000. So that 20 errors a month was a 0.1 per cent error. We investigated it thoroughly, we took plenty of positive action, gave lots of support to the staff, and got changes in practice that won’t reduce it from 20 to nothing, but will reduce it from 20 to ten or something like that.
‘I can go round any of my colleagues and senior consultants, and they will all tell you the mistakes they made this week,’ says Dr Notcutt. ‘Maybe at a small level – you pick up a wrong ampoule, you draw up the wrong ampoule – that goes on all the time. It’s a normal part of regular practice.’
Errors can be as much a result of system management as individual competence.
‘If you look at any medical error,’ says Dr Stephen Green, head of risk management at the Medical Defence Union, ‘it is very unusual for it to be a one-off act. It is usually a series of events, or you’ve got a designed-in fault that’s waiting to happen.’
Dr Notcutt had such an incident happen to him. ‘I found myself giving the wrong drug intravenously about three or four weeks ago because they’d changed the boxes in theatres. I’m thinking about a problem with a patient in theatre, I’m also drawing out some drug to deal with the blood pressure – and because they’ve changed the boxes, I identify one thing and actually it’s another thing.’
Dr Graham Neale, is a retired consultant physician and a co-researcher in the BMJ study Vincent et al. He acted as series consultant for Channel 4’s documentary in October, Why Doctors Make Mistakes, and now works as a consultant for the Association for Victims of Medical Accidents.
He also knows what it’s like to make a mistake. ‘The last year before I retired I made an error which was one of a succession of errors with a particular patient, who nearly died as a result,’ he says.
‘That was a very painful process, but we were upfront with the relatives right from the moment he became severely ill. I was the head of the team that looked after him, trying to recover the situation – which we eventually did’ he recalls.
‘They sued us. He had this devastating illness and we just put our hands up and said: “Yep, we got it wrong.”
‘I think I needed my past experience and my age to be able to front into that without too much distress personally and without trying to cover it up; and I think you do need experience and you need a change in medical culture to be able to cope with that kind of situation.
‘But it’s very unpleasant and I was very distressed by it.’
Dr Neale adds: ‘So many of the people who approach AVMA say, “Look, please tell us what happened and tell us what you’re going to do to stop it happening.” Some of the trusts you just run into a brick wall – they either don’t reply or they reply defensively and that becomes very difficult.’
Dr Jo Bernstein, a consultant in elderly care, is the medical directorate lead for clinical governance at the North Hampshire Hospital. As a locum, she counselled junior doctors on adverse incidents.
‘One example involved an opiate, and they just misinterpreted a number – I don’t know quite how it was done, but they believed five actually meant 20 – and then they skimped on the two nurses checking.
‘When they handed over to the doctor who had written it up in the first place, they did not say “here is your 20mg”, they just said “here is the drug” and they just gave it. None of the doctors intend to cause their patients harm – there is just disregard of boring safety procedures.’
‘In one respect you are responsible,’ Dr Notcutt says, ‘because if your finger is on the trigger and you are the final pathway, you have a responsibility. But there’s a critical difference between being responsible – becoming the final pathway for what is often a series of minor errors that have led to a major one – and somebody being wilfully negligent and sloppy in their practice.’
Workload also contributes to the incidence of error. Dr Duncan Newton, a consultant physician at Bradford Royal Infirmary, says: ‘The general problem is that if you’re admitting between 20 and 40 people a day, the amount of paperwork generated is huge.
‘How do you make sure you don’t miss any vital info coming from the medical imaging department, the haematology lab, the biochem lab and from the bacteriology lab? You can see all the areas where there’s potential for going wrong.’
Dr Cole believes a culture of open reporting – of ‘learning and changing’ – is fundamental to helping to adapt systems to reduce errors.
Dr Newton feels such a culture is beginning to exist. ‘I would hope now that there is a very open environment in most British hospitals. If something goes wrong, it’s regarded as a risk incident and as such should be reported and discussed in an open fashion.”
But Dr Jeffrey McIlwain, of the Whiston Hospital, Prescot, has seen the other side of the story. Believed to be the only consultant in the country devoted full-time to clinical risk management, he reckons that, for open reporting to work as well as it might, there’s too much stick and not enough carrot.
‘We would learn better from the errors we have in the NHS if we had better openness, an acceptance by the profession that they have happened – but that has to be cultivated in an atmosphere that isn’t punitive. You can’t ask an animal for example to perform in a circus if you constantly thump it. It will do what you want it to do for the wrong reasons.
‘There’s a feeling of beleaguerment in the medical profession. No matter what we do, it’ll either be the politicians that are going to get us, the lawyers that are going to get us, or the media who are going to get us.’
Dr Bernstein would add the GMC to that list. A former elected member, she witnessed the ‘scapegoating’ of doctors during her five-year tenure.
‘They say that a really good doctor, who makes a mistake and it’s not negligence, has nothing to fear: they may have to explain themselves to everybody including the GMC, but in the end people will see they’re a good doctor and will understand it’s a mistake. And that’s not true.
‘Because I saw the same scapegoating and the same culture of blame – “we have to sacrifice this doctor because otherwise the message would be doctors can get away with making a mistake”.’
Even if you’re cleared of any misconduct, says Dr McIlwain, the media treatment can be destructive. ‘If the media effectively become judge and jury then where do you stand as a doctor? It doesn’t matter if you’re cleared by the GMC or you’re cleared by a court – the damage has been done.’
Mr Rupert Fawdry, consultant in O&G at Milton Keynes General Hospital, agrees. ‘We’re more concerned throughout the system with trying to find someone to blame, rather than “How can we find something positive about this accident so we can work out a way of trying to improve the system in order to make it safer?”’
Mr Fawdry is working on the benefits of pro-forma IT systems to make the consultation process less error-prone. ‘The primary aim of computers should be to reduce the stress, the errors and the fear of litigation for individual doctors looking after individual patients,’ he says.
In an effort to monitor adverse events and near misses, Prof Liam Donaldson, Chief Medical Officer for England, proposed setting up a national database.
The Department of Health had pledged last June to have this system in place by the end of 2000, but Health Secretary Alan Milburn now says it will not be ready until the end of this year.
Trusts will be informed when patterns of mistakes arise and, in the worst cases, the Commission for Health Improvement may be called in to investigate. There will also be a confidential hotline for staff to report incidents. Both NHS and private hospitals will use the system.
This initiative could also encourage doctors to be more open with their patients, something Dr Green suggests is the way forward.
‘Doctors should recognise that an open and honest explanation of what’s gone on is very helpful. Give an appropriate apology – that’s a human thing to do that’s often what patients are looking for.
‘Very often in the past I’ve heard it said – and I’m sure it’s true -that patients have gone to litigation to get an explanation of what happened.’
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