MAKING MISTAKES IS the worst part of being a doctor. I have made errors of judgment and technique, committed sins of omission and commission. I have erred through inattention, inexperience, inadequate supervision or equipment.

We doctors work in a charged environment of stress, overwork and constant disruption, a fertile ground for error.

To the best of my knowledge I never caused a patient’s death but I’ve been lucky on several occasions and have had colleagues bail me out on more. Like most doctors I remember the detail of my errors and the guilt and shame I felt on account of them are burnt onto my mind.

I have written before about attention to detail. And that’s important given that I spend a large part of my working week staring down a 2.5mm lens into colons covered in mucus and human faeces looking for things ranging in size from the full stop on your screen to a small wart that might one day grow up and kill someone.

Blame and shame

Medicine has long fostered a culture of blame and shame where we have tried to divide doctors into two groups: those who make mistakes and those who do not. And we believe if we weed out the latter all will be well. This is a fantasy that does patients a disservice. If people can’t open up about mistakes, how can others learn?

How do we get the small voice in the back of the head of the doctor who has erred and, not had it been noticed, to put their hand up and report it?

It won’t happen in a culture where condemnation and calls for resignations, sackings and prosecutions from the fevered hothouses of social media, traditional media and parliaments have become the norm.

In addition, legal advocates for patients harmed by error provide an invaluable and much-needed service but their pronouncements on cases they are involved in should not be treated as independent unbiased analysis by the media and politicians.

Error rates

In Ireland, error in Medicine has been thrown into sharp focus by a number of tragic incidents that have come to light, most recently a lookback review into the work of a locum radiologist (a consultant who reads CT, Ultrasounds and X-Rays) employed in University Hospital Kerry from March 2016 to July 2017.

Numbers can seem cold, but 46,234 scans read by this doctor were reviewed on foot of concerns having been reported of missed diagnoses.

The doctor was accurate 97.04% of the time. Of the remainder 105 (0.22%) had findings of potential concern. Eleven patients (0.023%) were then identified as having a clinically significant unreported finding in the original report which led to a delay in diagnosis and treatment, four of whom have since tragically died.

This knowledge will add to the grief and pain of those affected and it is they who should be at the centre of people’s attention and sympathies.

To provide some context, of the 1 billion scans performed worldwide every year, the day-to-day error rate is estimated to be at least 3-5%. 

We must always strive to reduce error and the circumstances of the individual cases are unknown, but the raw data revealed by this forensic audit has revealed the performance of a locum working flat-out at an understaffed, under-resourced medium-sized district hospital in rural Ireland lies very much at the high end of what is expected.

I understand why medical error arouses strong passions. I am both a patient and a relative myself and I know how medical error feels from those sides too. But if we are to move to a place of accountability, safety and quality improvement then honesty and facts are the keystones.

A frequent frustration for many commentators is talk of systems failures rather than individual culpability when hospitals fall short. Designing systems that minimise the impact of inevitable human error is the life’s work of safety trailblazers.

In a “just culture” front-line staff feel confident to speak up when things go wrong. People are not punished for actions, omissions or decisions which are commensurate with their experience and training, but gross negligence, wilful violations
and destructive acts are not tolerated.

A just culture prioritises patient safety, enables organisations to learn from their mistakes and quietly saves lives.

It would rigorously investigate and see what could be learned from what happened in Kerry but would also notice that the overall error rate was exceptionally low even by the highest international standards and ask what could be learned from that too. A just culture is the only ecosystem that will allow Open Disclosure to truly flourish.

It’s important that everyone understands the limits of the people and the technologies that we rely on for our healthcare. The slow grind of quality improvement is all about attention to detail and we must take it seriously because lives depend on it. The excellent recommendations of the Kerry report are mainly about structures and systems, peer review and audit, as they should be.

They speak of giving doctors dedicated time and space to engage in quality improvement, defining safe workloads, things I found to be cherished when I worked in the US and the UK but is perceived as a waste of time by managers here.

Follow the seanfhocail

Lucian Leape and Don Berwick of the US Institute for Healthcare Improvement’s work is decidedly unsexy: they study the management of healthcare systems, using scientific evidence to improve the trade-off between quality, cost and safety.

But their work is important. Leape’s seminal Error in Medicine paper in 1994 estimated 44,000-98,000 deaths occur annually due to medical error.

Renowned surgeon, author and patient safety advocate Atul Gawande once wrote: “No matter what measures are taken, doctors will falter, and it isn’t reasonable to ask that we achieve perfection. What is reasonable is to ask that we never cease to aim for it.”

Gawande devised a two minute pre-surgery checklist which when implemented resulted in a reduction from a 25% likelihood of missing key life-saving steps in an operation to a 6% likelihood: a 75% reduction in error. Again, decidedly unsexy, but literally lifesaving for a silent multitude of patients.

The first thing that greets you on the Vision, Mission, and Values page of the Leape and Berwick’s Institute for Healthcare Improvement website is this:

There is an Irish proverb that says that ‘When you come upon a wall, throw your hat over it, and then go get your hat’. At IHI, the spirit of this one little saying has inspired many big outcomes.

It will strike many people as ironic that this global leader in patient safety looks to an Irish seanfhocail for inspiration.

The future wellbeing of our health service and safety of our patients demands we take the fruit of their labours and implement them here.

Anthony O’Connor MD, MRCPI is a Consultant Gastroenterologist at Tallaght Hospital.