To err is human but medical errors can be dire
Everyone makes mistakes, but a doctor’s mistake can be lifechanging. Health reporter Mike Houlahan looks at what happens when things go wrong.
IT takes courage to own up to mistakes, especially for a medical professional, whose error or omission can have profound effects on a patient — and on the medical professional’s own working future.
This week the Otago Daily Times spoke to two women who have just months to live after scans which showed their — at the time operable — cancers were not properly acted upon.
The story of the first — a woman whose gynaecological cancer scan was not looked at for 27 days and then deleted by her GP without any followup — drew hundreds of comments on the
ODT Facebook page, many revealing their own stories of mistakes.
Medical professionals do not want to make mistakes — but mistakes do happen.
Just how many annually cannot be gauged, but ACC statistics offer a clue.
In OtagoSouthland there were 478 new claims for medical treatment injuries in 201718, and 980 claims are still active. Which sounds enormous. But given how many hospitals and clinics there are and how many procedures are carried out on a daily — let alone annual — basis — as a percentage, the number of mistakes is probably small.
This might be comforting, unless you are affected by the mistake — for those people, an oversight or a slip has enormous implications.
The most serious of those cases usually come to the attention of the Health and Disability Commissioner.
In the 201617 year the commissioner received a record number of complaints — 2211 nationwide, a rise of 13%.
In 201617 the commissioner closed 2015 complaints, 85% within six months, and 80 formal investigations were completed — with 61 resulting in a breach of the Health and Disability Code being proven,
Of those, 11 were regarded as being so flagrant the providers in question were referred to the Director of Proceedings for potential prosecution.
The Director of Proceedings is now considering whether the Southern District Health Board should face charges over the care of Koby Brown, who lost the sight of one eye due to delays and missed opportunities to remedy his condition.
Big or small, if a mistake has been made by a medical professional in the SDHB region the details will probably end up on the desk of chief medical officer Nigel Millar.
When the SDHB apologises for a mistake, it is usually Dr Millar who does so.
‘‘Personally, I feel the tragedy when I read and hear and talk to the people who have experienced these things. I think it’s just awful they find themselves in these situations.
‘‘They trust us, we have let them down and we have to be upfront about that.
‘‘And it is a hard thing. I would hate to write false, insincere things — it is real.’’
Dr Millar said the complaints process was an important part of improving the medical system and it was vital people spoke up if something went wrong — and the sooner the better.
‘‘If you are receiving treatment and it feels like something is going wrong, say so, because you may be the unlucky person for whom something does go wrong,’’ he said.
People needed to expect their doctors, nurses and clinicians could make mistakes, Dr Millar said.
‘‘People on the outside might think that sounds terrible, but if we grow a model where we expect health professionals to be perfect and they expect it of themselves, it creates a difficult set of circumstances where you are asking the impossible.’’
The SDHB wanted its staff to be open about errors and move to fix them as soon as possible, Dr Millar said.
The first priority was to tell the patient what happened, and then try to help them.
Secondly, equipment and processes were examined to see if anything could be fixed immediately. For example, in one case, when it was discovered a drug had been mistakenly put in a saline drip, the drug was immediately moved elsewhere to avoid confusion in the future.
In another case, when it was discovered tubes for gastric feeding also fitted on to intravenous drips, different fittings were introduced.
Incidents were then reviewed to see what underlying factors were involved.
While the process might seem lengthy and cumbersome, mistakes were often due to complex circumstances, Dr Millar said.
‘‘We are still struggling to deal with issues of straightening out our systems and making them simple and reliable so people don’t have to remember everything — that if they forget something, it doesn’t cause a tragedy because there are backup systems and things are designed properly.
‘‘The difficulty is the complexity of health, because the technology and amount of information is growing faster than we can manage, and it only takes one little thing to go wrong.’’
If an error is raised to the level of the Health and Disability Commissioner, one vexed issue is anonymity.
Clinicians, patients and most providers are anonymised in reports, a policy instituted because reports are intended to be educational and a policy of blanket name suppression ensures maximum cooperation, the HDC website says.
Research also shows clinicians are more likely to report their mistakes if they have no fear of attendant publicity.
The counterargument — as expressed by many ODT readers this week — is that the public has a right to know if it is their GP, medical practice or specialist who is involved.
‘‘I can absolutely see both sides of that and it is a really difficult one.
‘‘We like to try to be as open as possible so that when things do go wrong we are accountable.’’
Mistakes affected many people — doctors, clinicians, family and friends as well the patients involved — and were a reminder of the weaknesses and strengths of humanity, Dr Millar said.
‘‘At the end of long and difficult conversations about people’s dissatisfactions, concerns and tragedies, almost everyone says ‘I just don’t want it to happen to anyone else’.
‘‘At that time you get a lump in your throat and think how amazing people are — they go through these things, and then they set about trying to do something about it.’’