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Mistakes: ‘focus on preventing recurrence’ Luke

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01 January 2017, at 12:00am

DON’T BLAME THE VET when an operation goes wrong or a patient receives the wrong medication: it may be the system at fault rather than the individual.

Speaking at the recent BVA congress on the cause of errors in human and veterinary practice and how they may be prevented, Anne Pullyblank, a consultant surgeon with North Bristol NHS Trust with a particular interest in patient safety issues, said that in terms of risk, “hospital treatment is up there with bungee jumping, which is not something that I would choose to do”.

This issue has been examined more thoroughly in NHS hospitals than in veterinary clinics – and with good reason. About 11% of patients treated in hospital experience some form of adverse event and in about one-third of those cases the consequences can be death or disability, she said.

Indeed, the problem may be worse than the of official figures suggest. “We are supposed to report such events but doctors are less likely to do so than nurses, as they forget. It has been estimated that nine out of 10 preventable deaths are not recorded, so we may be seeing the tip of the iceberg,” she said.

One of the main problems is that medical staff tend to “normalise” the harm that they cause to patients. “We used to think that Clostridium dificile infections were just something that happened to very sick people. But if you do all the right things – washing your hands, giving timely and appropriate antibiotics – the incidence of central line infections can be reduced to zero,” she said.

The main cause of medical mishaps is that hospital staff are human and they do make mistakes. Such errors are much more likely when people are put under pressure and this overcomes their capacity to deal with stress.

Modern medicine is an increasingly complex activity and “even women have a limited ability to multitask”, she said. So when concentrating on the main task, it is easy to miss out on other things going on in the operating theatre, sometimes with disastrous results.

As it is impossible to eliminate human error, mistakes are less likely in a team situation than for those working alone. So systems should be put in place to ensure that colleagues will identify and deal with an emerging problem. 

Also, when mistakes do occur, it is important to steer away from apportioning blame and to focus on preventing any recurrence. Miss Pullyblank said that in addition to the patient who suffers harm, there is often a second victim of a medical accident.

These are the clinicians who believe themselves to be responsible: “I have known cases where that person has been destroyed by the event – and has not been able to work again.”

Introducing a system of surgical checklists has been shown to be hugely effective in reducing the risk of adverse events, she said. One study has shown that the death rate during and after surgery can be reduced by 50% and the numbers of patients experiencing post- operative complications reduced from 11 to 7%.

Checklists are now used routinely in the NHS system and the concept is beginning to take hold in the veterinary world. An Association of Veterinary Anaesthetists member in the audience said the association has already developed a customised version for use in companion animal clinics, while Catherine Oxtoby from the Veterinary Defence Society said the VDS was working on a range of documents for different situations in practice.

Miss Pullyblank acknowledged that checklists will not eliminate all sources of medical error, but they are a vital safeguard and will also improve communication between different members of the team.

Surgical staff have much to learn from those working in the catering trade for companies like Starbucks: “When they ask for your order, they will repeat it back to you to make sure that they have got it right – this is called closed loop communication and it is really important,” she said.

Another important element in ensuring that a surgical team communicates well is to “ atten the hierarchy” and ensure that the junior members can have their say. She recalled the investigation into an incident at a Welsh hospital in which the patient had the wrong kidney removed.

“There were two people in that room who knew that the surgeon was making a mistake: one person said nothing and the other was a medical student whose objections were brushed aside.”

Dr Oxtoby emphasised the need to learn lessons from any adverse events. But when discussing an incident during a morbidity and mortality review it was necessary to focus on the events that led up to the error being made rather than simply discussing what happened and the clinical consequences.

Miss Pullyblank added that examining “near miss events” would be equally informative – this was standard practice in the aviation industry and was now beginning to be part of NHS practices.

NHS staff were often reluctant to acknowledge their mistakes in front of patients, she said, lest that made it more likely that they would sue the hospital trust – but she encouraged colleagues to admit an error. Patients who have suffered harm are not normally vindictive in wanting punishment for the person responsible.

“What they want is to know that the same thing is not going to happen to someone else. We must also acknowledge that in many situations it is appropriate that patients should receive compensation for lost income when they are unable to work. Compensation and blame are entirely separate matters.”