Tuesday, September 16, 2014

Avoiding Errors In Medicine

There's a difference between being cavalier and being a cavalier.
Over the last decade or so there has been a trend in medicine to discuss and disclose error. This has coincided somewhat with a cultural shift away from a person-centered approach (individuals – and their inattentiveness, forgetfulness and carelessness are to blame) towards a systems-based approach (starting from a position that to err is human, but systems can be designed in such a way to minimise the risk of error) and that makes sense.

Usually when errors are investigated, multiple contributing factors are identified. (It’s one reason why I enjoy watching Air Crash Investigations even though I hate flying – usually there are MULTIPLE things that go wrong – it’s not usually just a drunk pilot or a leaky fuel tank or a dodgy fuel indicator that brings the plane down…it’s when all three happen at once that disaster strikes). Moreover, people are hardly going to be open about error if they know they are going to be scapegoated or hauled over the coals.

Incident reporting, clinical audit, retrospective case note review and morbidity and mortality meetings are increasingly common in human teaching hospitals as a means of quality control but also to identify actual and potential errors and minimise the risk of these occurring. One reason these strategies are less common in the veterinary setting is that we have smaller, less complex systems. It can be much easier to trace the root cause of an error in a smaller system. That said, veterinarians are just as capable of erring as human doctors and we can learn a LOT from our human-treating counterparts.

The difference between a good doctor and a bad doctor is not that the latter makes errors whilst the former does not. Rather, a good clinician learns from errors [a quick aside here – The Bad Doctor is also the title of a very awesome graphic novel which puts paid to the notion of perfect doctors – read more here].

The Bad Doctor...is actually a really GOOD read.
Avoiding Errors in Adult Medicine(Wiley-Blackwell) is designed so that doctors and medical students can learn from the errors of others – but this is an excellent read for vets and vet students also.

Many errors, of course, do not result in poor outcomes (these are the “near misses”). But some are devastating. The authors estimate that one in ten patients admitted to hospital in the developed world are the victim of error, and 1 in 300 patients admitted to hospital dies as a result of such an error.

“Healthcare professionals tend to act in good faith and medical error has many victims – patients, families, those very medical professionals (and their families)…”ix
 The authors have done a brilliant job in researching a range of cases, commenting on the specific details of these (including medicolegal comment) but also drawing out general pearls of wisdom (these could equally apply to veterinary patients). Here are my favourites:
    1. “It is easy to identify a severely unwell patient. The challenge is to spot the patient who is not yet severely unwell but who may deteriorate rapidly if he does not receive the right treatment. Such patients present alongside hundreds of other patients with self-limiting conditions.”p12
    2. “When cases involving sick patients who were not correctly identified are reviewed, it is often found that the patient had a single abnormal parameter and that this was not acted upon.”p13
    3. “…it can equally be that sometimes, when patients are seen very early in the course of a critical illness, that there are no early warning signs of a severe illness to identify. This only serves to reinforce the need to give patients very clear ‘safety net’ advice, when they are discharged from medical care: that is advice about when they should re-attend the ED or the GP, if the patient fails to get better. Such advice should be given no matter how trivial the presenting complaint may appear to be.”p12
    4. “Practical procedures require good communication skills, manual dexterity, patience, a calm and gentle touch, and supervised practice…The objective should be to perform the correct procedure on the correct patient, on the correct side, competently and with appropriate consent.”p13
    5. “The term ‘Units’ should be spelt out in full when prescribing (e.g. insulin or heparin) in order to reduce the chance of U being interpreted as ‘O’ leading to a tenfold error.”pp15
    6. “…make sure you develop the competence before the confidence…have regard to your position on the spectrum from cavalier under-investigation [did make me think of a Cavalier King Charles Spaniel…] through to defensive medicine.”p59
    7.  “Keep calm in all clinical interactions and step away from the situation where necessary…If you are upset defer practical procedures where possible. Seek advice from senior colleagues when you are in a situation you have not faced before.”p102
    8.  “Whenever you propose a diagnosis or explanation ensure the facts fit the mechanism you propose. Be logical and analytical – it is why you spent years learning basic anatomy, physiology, biochemistry, pharmacology and pathology.”p116
    9. “Doctors who make mistakes may become better at their jobs as a result. They can, and do, go on to have successful and productive careers. The key is to reflect on errors and pay heed to any lessons that can be learnt.”p164

    It all sounds crystal clear and very obvious, but the retrospectoscope has 20:20 vision. When one reads about the challenges these health professionals faced at the time the errors were made, at least in some cases, one can understand why someone made a particular decision or assessment, or how easily an oversight was made. It’s a very good reminder of the kind of mistakes almost anyone can make – and the life-saving importance of learning from these.

    If you like this book, you'll also enjoy The Bad Doctor (more here) and How Doctors Think (more here).


    Ian RecklessD. John ReynoldsSally NewmanJoseph E. RaineKate Williams,Jonathan Bonser (2013) Avoiding Errors in Adult Medicine. Wiley-Blackwell. ISBN: 978-0-470-67438-3