Errors in healthcare are a worldwide phenomenon, and there are a number of factors involved, writes Dr Muiris Houston, Medical Correspondent
THE REVELATION last week that a child with kidney disease had the wrong organ removed at Our Lady’s Hospital for Sick Children in Crumlin has again focused attention on errors in healthcare.
Wrong-site surgery is the term given to mistakes involving an operation on the wrong body part or the wrong patient.
Risk to patient safety first came to public attention with the 1991 Harvard Study. It looked at the records of 30,000 US hospital inpatients and found that 3.7 per cent had experienced an adverse event during their stay.
But subsequent Australian research found even higher rates. Some 14,000 patient records were examined as part of the Quality of Australian Healthcare Study – 16.6 per cent of patients had experienced some kind of adverse event while in hospital.
The Danish Medical Association estimates that 11 per cent of hospital admissions lead to harm to patients. Denmark has a population of almost five million, and the president of the Danish Medical Association has suggested there could be 1,500-5,000 deaths there annually due to hazardous healthcare.
We are no different. Figures from the State Claims Agency show there are almost 1,000 adverse incidents in Irish hospitals weekly. While the majority of incidents were minor in nature, in a 21-month period ending in September 2006, the agency logged 1,663 compensation claims arising from healthcare error. A quarter of these relate to problems involving surgical care.
Why are patients injured in hospitals? In simple terms, adverse events are due to either human error or systems failure. But, in practice, it is often difficult to separate the two, because most human error occurs in the context of the system within which the healthcare personnel operate.
Most healthcare error has been shown to occur when the professional thinks they know what they are doing but fails to notice a contraindication or apply the correct rule to their action.
How could a well-qualified surgeon not know he was removing a healthy kidney? An inwardly diseased kidney may look normal, and any chance of re-implanting the good kidney evaporates once it is placed in preservative prior to pathological examination.
Risk factors for wrong-site operations include the involvement of several surgeons in the same operation; time pressure; emergency surgery; and when a patient has an organ that is not in its usual anatomical place.
Research into 300 cases of surgical error by the US Joint Commission on Accreditation of Healthcare Organizations found that 59 per cent of cases involved surgeons operating on the wrong side of the patient. Some 10 per cent involved the wrong procedure and 12 per cent involved the wrong patient – 19 per cent, the wrong body site.
In 2004, new rules were introduced in the US, requiring doctors and nurses to take a formal “time-out” before beginning an operation. The pause before the first incision is made means staff must verify the correct patient is on the table. They must communicate clearly the site to be operated on and the procedure they plan to carry out.
This time-out should be conducted in a “fail-safe” mode so that nothing is done until all questions or concerns from the operating team are clarified.
However, a 2007 US study of wrong-site surgery in Pennsylvania found that formal time-out procedures failed to prevent wrong-site surgery in a small number of cases.
The use of body site markings, where the surgeon uses indelible marker to mark the exact incision line he will use when operating, has also become standard practice. Designed to visually identify both the correct side and correct level for the incision, site marking is, ideally, performed before the patient enters theatre.
The person should also be awake, allowing the surgeon to confirm the appropriate site with them. Significantly, the US study found that in the case of near misses, it was usually the patient or the circulating theatre nurse who intervened to prevent wrong-site surgery.
Brian Toft, professor of risk management at Coventry University, has identified a phenomenon called involuntary automaticity (IA) which might help to explain human error and why it persists.
IA is a cognitive mechanism that causes people to miss cues that are right before their eyes, despite double-checking protocols. Significantly, Toft says high workloads, stringent time pressures and staff shortages are all causes of IA.
Part of the limited information made available by Crumlin hospital is that the child has been discharged and is back at school. We do not know whether the victim requires dialysis or can function with the remaining diseased kidney.
But it is possible that the child will require further transplant surgery. As for the surgeon and the hospital, they may face legal action for damage caused by this regrettable case of wrong-site surgery.