Don't blame me, I'm only a doctor

Medical errors happen all the time, and most of them go unreported, admits Ed Walker. But making scapegoats of NHS staff won't achieve anything
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They used to say that doctors bury their mistakes. Not any longer. They are more likely to be found discussing them in court, while facing a charge of manslaughter. A culture-shift which sits rather awkwardly beside the notion of "no-blame" reporting for medical accidents, something that everyone, from the British Medical Association to the new National Patient Safety Agency, seems to think is a really good idea. If you are sitting comfortably, let me tell you some stories, which may convince you that giving doctors a comprehensive bollocking may not always be the correct course of action.

They used to say that doctors bury their mistakes. Not any longer. They are more likely to be found discussing them in court, while facing a charge of manslaughter. A culture-shift which sits rather awkwardly beside the notion of "no-blame" reporting for medical accidents, something that everyone, from the British Medical Association to the new National Patient Safety Agency, seems to think is a really good idea. If you are sitting comfortably, let me tell you some stories, which may convince you that giving doctors a comprehensive bollocking may not always be the correct course of action.

Part of the house officer's duties when I was a lad, was to give intravenous antibiotics to post-operative patients, and there were sometimes 20 or more of these doses to be given of an evening. It was my practice, like that of every other zombie-faced junior in the place, to mix up batches of the drugs before trudging off round several wards to inject the life-saving elixir.

These rounds often took on the dimensions of a Forth Bridge paint job. No sooner had you ticked the list off once, then it was time to do it all again. Towards the end of one round, I was injecting on auto-pilot when I noticed that this particular syringe felt a little lighter than the rest. That was because it was full of air. Thankfully, I stopped before injecting more than half a millilitre. Opinions vary as to exactly how much damage a full 20mls of air will do if injected intravenously, but they only vary between permanent brain damage and sudden death.

Some weeks later a man who was three days out of major surgery suffered a cardiac arrest. I pitched up with a fellow house officer, and both of us realised that something was amiss, the patient having no pulse. The ward sister had called the cardiac arrest team, but we were a little stuck for what to do until they arrived. But we knew that if the patient's heart wasn't beating, he would not be perfusing his kidneys with blood, and so it might be judicious to measure his urine output, by placing a urinary catheter. So the crash team arrived to find two junior doctors fiddling around with their patient's penis.

While you might think these two mistakes bad enough, neither, thankfully, had a truly drastic outcome. Not like the 18-year-old who comes in to have his wisdom teeth removed, and ends up in a vegetative state because there was too little oxygen in the mixture of anaesthetic gas. Or the woman with a minor abscess, who tells everyone religiously that she is allergic to penicillin, only to be injected with a fatal dose of co-fluampicil because someone did not realise that, too, was a penicillin-based drug. But I have been close; like every other doctor I know the bowel-mobilising power of that sudden moment of realisation. The sudden pounding of blood in the head, the ringing alarm bells that signal you just did something very, very stupid indeed.

And it comes when you least expect. Not the difficult case you have prepared for, but the minor procedure, when your defences are down. Like the pea-sized lump I was "given" to remove from a man's wrist under local anaesthetic. It was very straightforward until the patient started complaining of tingling in his hand. I suddenly became acutely aware that the lump was probably a neuroma of the median nerve, something you need a microscope to remove safely, if your patient is to have a useable hand afterwards. I knew all this because an identical case had been reported in a recent journal. And just as my mouth went dry, the little pea, popped out all on its own. A sebaceous cyst after all. Panic over. For now.

Nowadays these would all be called "Clinical Incidents", and there is a system in place to report them. Everyone is encouraged to do so, the stated aim being to improve standards of patient care. But many doctors feel increasingly victimised by such a system, which seems to be used simply to try and "root out" those who make mistakes, missing the rather salient point that all doctors make mistakes.

A new survey by the medical website doctors.net.uk found that 82 per cent of doctors had seen colleagues making mistakes. It found that only 15 per cent of these had been reported. Of those surveyed, 97 per cent said that they thought a "no blame" system of confidential reporting of hazards and mistakes would improve patient care.

Here's how Clinical Incident Reporting is supposed to work. Something happens that shouldn't have. Maybe it's one of those grace of God things, maybe it is an error of judgement, or perhaps something more serious. Such occurrences can now be reported by anyone concerned to a department in their hospital which is usually called something like "Risk Management". While the reporting is not anonymous, it is done in a blame-free, sharing, caring, learning sort of way. All those involved meet up over a cup of decaf and a free NHS cheese baguette, reflect constructively on what has happened, and give each other a hug before going back to their jobs, enriched by the experience and better empowered to perform effectively as stakeholders in the carer-client partnership. And here is what really happens.

You only have to look at the forms involved, which are of Kafkaesque proportions and complexity, to realise that attaching the tag of "blame-free" to the current system is like suggesting that Harold Shipman was merely misunderstood. You must state whether it was an actual incident, or a "near miss", which only had the potential for doing harm. You must decide whether the damage caused to a patient was minor (e.g. a bruise) or less minor (e.g. permanent disability and/or death). You must not deviate from the guidance notes provided when filling in the form. The events leading up to the event must be outlined, as well as the parts played by any persons(s) involved, all of whom must be named.

The "examples" of clinical incidents include performance of an operation that is not indicated, operations carried out on the wrong patient/body-part/side, inadequate monitoring during an operation, delay in attending to patients, failure to correctly interpret x-rays and ultrasound scans, inappropriate use of forceps in a delivery, surgical instrument(s) left inside after an operation. Nobody suggests that events like this shouldn't be recorded somehow, but only if there is real potential for preventing a recurrence. As it is, when it comes to reasons for reporting, vindictiveness and spite directed towards a colleague are at least as common as a true desire to improve the care of patients.

It's not only doctors who sometimes get things awfully, inexplicably wrong. Take, for example, drug companies. Say you manufactured two different drugs. Both are colourless, and come in one-millilitre doses. One is given at the end of an anaesthetic to help wake the patient up; the other is only given in emergencies and can stop a heart beating. You would put them in different shaped bottles, wouldn't you? Or at least have different coloured printing on them. The one thing you certainly would not do is put them in identical phials with tiny writing on it so that the only way to tell one from the other is with a magnifying glass. Bafflingly, that is exactly what all drug manufacturers did with atropine and adrenalin for years, and most do still.

Drug packaging errors are common. Local anaesthetic gets mixed up with sterile water; morphine is given in doses 10 times larger than it should be, all for the want of a little red ink. The response of drug manufacturers to the steady dribble of patients who are killed or injured by confusing labels is that practitioners must be more careful in their reading habits. Which is I suppose fair enough, but only up to a point. If you buy a pack of croissants which contain even a whiff of peanuts, you can hardly get it in the trolley for warning labels on the packet. Intravenous drugs are regarded by most experts as more dangerous than pastries, yet there is currently no legislation in place which governs their labelling.

If your child was killed by a stupid, avoidable medical mistake, you would probably demand the culprit's figurative balls in a bap, with some justification. But you need to be sure who the culprit is. One effective way to kill a child is to inject their spine with vincristine, a chemotherapy agent used to treat leukaemia. This mistake has occurred a dozen times at least in the UK in recent years, and the incident was reported in one way or another each time. The amount of blame apportioned to the doctors concerned has varied considerably - some charged with manslaughter, some not; some acquitted, some convicted.

The legal, culpability-led route seems to have made no difference at all to the incidence of this particular mistake, which is hardly surprising; you can never legislate against carelessness. What you can do is force drug manufacturers to present vincristine in such a way that it is impossible to inject it into the wrong place. This still has not happened. Blame-free or not, our current system of recording medical errors - and more importantly of acting on the results of such reports - is on the critical list.

The author is an A&E doctor working in the NHS

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