Friday, July 3, 2009

We all make mistakes - even doctors and nurses

We all make mistakes, in every area of our lives. Some are trivial like this morning when I forgot to listen to my wife when she going out. Was totally engrossed in fixing (unsuccessfully) computer problem. About 1/2 and hour later I realised that she had gone and that I was supposed to be looking after the kids. Fortunately no harm done.

As for more serious mistakes being dyslexic I have had my full share of these. Like using Internet banking to pay the wrong person $400. Or the grammatical error on the front page of my masters thesis. A spelling one that could have been very serious was in a report I did about milk clots. Did you know if you change the middle vowel of clots for an "i" you get a very different meaning! I wrote the report and circulated it with the senior management team. Fortunately they saw the funny side and I was very grateful that it was caught before going external!

So in the medical area you also would expect people to make mistakes. That's part of being human. And the way we treat our health professionals by being short staffed, having time and money pressures, the large volume of paper work that needs to be done etc etc. One would expect the errors under these conditions to go up.

Most people who go into hospital have a list of "almost" errors and/or actual errors. When I was in hospital with a spontaneous popped lung 3 days before my wedding date (yes the wedding date was moved!) the following issues occurred. I have x-rays like the one to the left were only one lung is showing. The lung is difficult to see on the x-ray but is the translucent bulb at bottom of the ribs.

Firstly because it was Thursday night of Easter, there was only skeleton staff. So after the young doctor in A and E had finished the surgery, done under local, he said "that went well, it was my first time I have done one of those" or words to that effect. I though "glad you told me that after the surgery". In theory this is not supposed to happen, but due to stretched staffing this was what happened.

Secondly when I was parked up recovering in the hallway /passage some guy stoned on Magic Mushrooms "fell" into me as he tried to walk by himself. Again nothing serious but a red flag.

Thirdly I was put into a "wrong" ward. I can't remember why, something about staff numbers or the such like. So I was in a non heart/lung ward. They nurses came to plug my chest drain (see graphic to right, credit wikipedia) into a vacuum, thus creating a vacuum in my chest for the lung to move into. So they were about to plug my chest drain into a yellow vacuum pipe that ran around the wall. Underneath the vacuum plug/socket there was a sign that said something about not using this vacuum for humans. So fortunately the researcher in me was with it enough to ask - shouldn't you not do that as the sign says not to. Fortunately they listened and figured out that this was not a good idea.

Lastly my lung had stopped "bubbling" in the water from the chest drain, thus implying it was fixed. So I called in a nurse in the middle of the night to check. This nurse tripped on the drain apparatus and caused the lung to start bubbling again.

Now am I upset about any one of these? NO. The medical staff were wonderful, helpful, listened to my questions, kind and efficient at all times of the day or night. Would highly recommend the staff to anyone. I am very grateful that they potentially saved my life, that they nursed me back to "full" health.... I choice to look at the good they did, not the bad.

The Total Quality Management (TQM) guru Demming says a number if important things. One of them is the concept of collecting the right data. For improvements cannot be made unless you have the correct data. Another is that you can't have an environment of fear, nor should you collect useless statistics that the people working have no real control over (eg budget blow outs).

The hospital system is set up to such that data collection of issues, like the ones above, is totally ignored. There seems to be the belief that medical people are 100% right all the time. And if anyone complains or there is a major issue (aka death of someone) then the people are hung drawn and quartered. So this results in a climate of fear and cover up, not of openness and honesty.

Without the right data, the right decisions need to be made. For instance there was not data collection about when stoned/violent people are in A & E. It wouldn't take rocket science to suggest that it might be Friday and Saturday night. So therefore extra security should be put in place.

Do we really expect our health workers to be perfect? To expect them never to make a mistake? Let us get real, everyone makes mistakes, and as long as we have witch hunts for when things go wrong the more innocent people will be harmed when systems are not changed.

I feel sorry for the health workers in the hospitals.

The good news is hopefully this lack of proper data collection might be changing. A resent study on a rest home in the Netherlands found that error rate in dispensing medication was 21.2% which is very high. The study broke down theses areas and did some fancy maths on them to extract out the risk factors. They found that the two most common errors were wrong administration techniques (incorrect crushing of medication and not supervising the intake of medication). Second most common error was wrong time of administration, being either 1 hour to early or 1 hour to late. They concluded that:

Medication administration in nursing homes is prone to many errors. This study indicates that the handling of the medication after removing it from the robot packaging may contribute to this high error frequency, which may be reduced by training of nurse attendants, by automated clinical decision support and by measures to reduce workload.

This is great to see that rigours statistical analysis of medical errors is occurring without punishing the people at the front line, as they are doing their best, and it is the systems that are at fault not the people (well in most cases).

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