accidents happen - even at hospitals

Stuff happens, or so the saying goes. Accidents are a normal part of life, not planned nor welcome, but a part of life none the less. I am amazed that we pretend that doctors/nurses/medical people don't make them. By this I mean that if a mistake occurs, it is a really big deal, investigations, paper work, careers on the line..... yet when a mechanic makes a mistake, apart from changing mechanics or getting angry we accept this as part of life.

There are systems that document mistakes in hospitals. However because of the big issues around reporting mistakes, it would follow logically that medical people would be reluctant to report them. Therefore they go unreported, thus the system can't improve. We should make medical mistakes "normal". That is accept them as part of life, so design systems that allow upfrontness about them. Thus systems can grow and change. Tiffany and I have had a season each were we spent a few weeks in hospital. In this experience we observed the following mistakes:

• First response person told Tiffany here ankle wasn't broken and removed the shoe and sock that should have been left on as compression. Ankle wasn't just broken is was shattered  
• Tiffany getting physio on her operated ankle days to early 
• Myself nearly getting plugged into a vacuum line that had underneath it "Do not use for patient drainage". She was able to plug me in - and I pointed out the notice..... they were short staffed due to the Easter break so I was in the wrong ward
• While I was in A & E I guy stoned out on magic mushrooms got up and wondered about before falling into me recovering from surgery. 
• My chest drain stopped bubbling in the middle of the night (a very good thing). Called a nurse and he tripped over the drainage machine, causing tube to move and chest to continue to bubble again 

I say this things not to point the finger not to name and shame. But to say in a busy hospital, with multiple pressing issues it is no surprise that things didn't quite go as planned. If I was in charge of quality I would be asking every exciting patent what went wrong. Until we have real data we cannot make informed changes. I would argue that these "minor" mistakes mentioned above would likely point to underlying issues which if left unchecked could cause serious harm.

I have said all that, because is the newspaper mentions patient fall top the number of serious injuries/mistakes that happen in hospitals every year. From what I can work out serious injury/mistake is one that causes death!. No surprise really, falls is the number one at home to. Apparently these incidents occur at 0.037 % which calculates out to be1 in 2702. So your odds are rather low. The question I have is anything done to track the almost mistakes? the "minor" issues that could lead to system improvements.

Or maybe fundamentally the hospitals don't care. They are happy to employ junior doctors for 12 days straight at 10 - 12 hours days without toilet or meal breaks. Clearly this doesn't result in optimal staff, nor optimal decisions. So therefore I have to conclude that hospital management don't really care about optimal procedures, just about getting people out the door.......