Can you imagine the pain of going to the hospital for surgery and having to go back to the operating room to have tweezers removed because they are left in your abdomen.
Or having left hip surgery because of years of agonizing pain and waking up to find out they operated on your good hip. Or have surgery to preserve your ovaries – but they were accidentally removed. Or, worst of all, realize you’ve had a procedure that was meant for another patient.
Made up imaginative stories for a TV drama? Unfortunately not. These were just some of the horrific accidents that have occurred in hospitals in England in just ten months. They appeared in a ‘never events’ list published by NHS England a few weeks ago.
Never events are the most serious of the serious medical errors. They literally shouldn’t be happening. But between April 2022 and January this year, there were 325 of these ‘never events’ in England alone.
Some argue that for an organization that has treated millions of people in that time, it is a relatively small number. But many of the patients behind the statistics are facing the catastrophic consequences.
Can you imagine the sadness of going to the hospital for an operation and having to go back to the theater to have the tweezers removed because they were left in your stomach, writes Professor Rob Galloway
These stories hardly inspire the public to put their trust in medical professionals.
So why am I telling you this? Well, behind the tragedies are important lessons for all healthcare providers – as well as anyone receiving medical treatment.
It is clear that these patients have failed; but pointing the finger of blame at individual doctors or nurses is not the answer. Apart from isolated cases of people who should be in prison, healthcare workers do not go to work and deliberately cause harm.
And simply blaming and scapegoating doesn’t solve the problem; it will instead lead staff to hide mistakes for fear of retaliation. It will also prevent future patients from benefiting from the learning.
Nor is it right for medics to blame themselves for the pressures everyone is working under, or the lack of resources, or say, “It’s just one of those things.”
These mistakes are just as common in better-funded hospitals abroad as they are in the private sector.
And it doesn’t just come at a huge personal cost to the patient: the NHS paid out £2.4bn in negligence claims in the year 2021/22 – and while the patient, or their loved one’s instinct, is understandably seeking compensation what they want most often is to make sure this doesn’t happen to others.
Not only the patient is affected. Several years ago I was involved in a case where medical damage was caused by overprescribing fluids.
The patient ended up in intensive care and I was wracked with guilt, depressed and on the verge of leaving the profession.
Professor Rob Galloway, pictured, admits to making mistakes when treating patients, writing: ‘I have come to realize that most mistakes are not due to a lack of care or knowledge, but because people are people’
Indeed, I have seen many colleagues suffer serious psychological damage and have seen their jobs terminated due to medical errors.
So how can this happen in 2023? And, most importantly, what can you do to protect yourself? Simply put, the reason most errors occur are ‘human factors’: modern medical care is incredibly complex and we as humans are not made for this level of complexity.
Trying to understand why medical errors happen has been on my mind for the past 22 years as a doctor: I teach courses and speak at conferences. You might therefore think that, with my experience and obsession with the subject, I should make no mistakes. Unfortunately that is not the case.
The more years I’ve worked as a doctor, the more I’ve come to realize that most mistakes are not due to lack of care or knowledge, but because people are people and our brains are designed to hunt, to run from woolly mammoths and reproduction; anything more complicated is difficult for us.
We are not really able to multitask, we communicate poorly, we assume we are right, we don’t like people who challenge us, and we don’t notice things that, from a different angle or over time, could change for us. may seem obvious.
Essentially, we are prone to error.
But we operate within a culture that does not recognize “human factors” and therefore does not take steps to eliminate them.
Professor Galloway wrote: ‘Several years ago I was involved in a case involving medical harm due to my over-prescribing fluids. The patient ended up in intensive care and I was wracked with guilt, depressed and on the verge of leaving the profession.”
Years ago I took care of a seriously ill patient. She lingers in my mind because even though we saved her life, my care could and should have been better.
I had asked for four units of cross-matched blood (blood of the same species as the patient).
Thirty minutes later I asked what happened to the blood and was told that someone told me her blood sample was mislabeled. Because of this, no blood was sent from the lab.
But I had not heard that message. I was too fixated and worried about other aspects of the care she received. So? I ordered new blood and it arrived 30 minutes later.
However, the delays affected her blood pressure and her kidneys – and she then required a significant stay in intensive care.
This wasn’t because I don’t care. I do care. It’s not because I’m lazy: I’m not. It’s not for lack of knowledge – I have a long list of letters behind my name. I made this mistake because I am human.
The solution is simple. My colleague could have said something to get my attention and make sure I was listening: “Rob, it’s important you listen: I have an update.”
Then I should have just repeated the crucial information. This is normal in high-risk industries such as airlines. It is even common in non-risky industries such as Chinese takeaways. I never got the wrong meal because when I order it it repeats for me.
This is the social and accepted normal practice in takeaway restaurants. But that is not always the case in healthcare facilities.
Last week I was asked by one of my junior doctors to evaluate a patient with a nasty infection and low blood pressure. I made a plan, with a step-by-step plan, including kidney function tests and an antibiotic drip. After I asked the physician assistant to repeat the list for me, she got defensive and said she had been listening. But I do this because in the past when I didn’t, treatment plans weren’t always followed and the patient suffered.
One of the things we doctors need to do is just use English and not medical jargon. It is so easy to confuse hyperkalemia with hypokalemia, with tragic consequences; less easy to confuse high and low potassium.
Another important way to improve patient safety is to ensure that following standardized practices is the norm.
I introduced “prompt cards” to my team for treating time-critical conditions, such as sepsis, with step-by-step reminders. These were based on Wetherspoons cocktail recipe cards, and they helped transform the care we give, reducing errors.
But what can you as a patient do to protect yourself? If you tell someone you are allergic to something, have them repeat it.
If you are being injected with a drug, ask to see what you are getting.
If you are about to have surgery, make sure you see the consent form and talk to the surgeons doing it. Ask, “What did I do today” – and always check that the arrow indicating where the surgery will take place is drawn on the correct side of your body and in the correct area.
Crucially, if you think something isn’t right, say so. Remember: you are the last line of defense. Don’t be intimidated by the medical staff. Help us to help you.
As physicians, our Hippocratic Oath tells us to do everything we can to not harm patients. But as humans, we are prone to making mistakes and we should do everything we can to reduce the chance of this happening. And that means really listening – to patients and staff.
And every day I remind myself of the mantra, “Don’t trust me – I’m a doctor.”
- Professor Rob Galloway works as an ER consultant. Twitter: @drobgalloway