To ensure their safety, patients must question practices of doctors and hospitals, writes Dr Muiris Houston, Medical Correspondent
The case of the late Kevin Murphy, the 21-year-old Cork man whose family received an award of €76,000 this week in the High Court, has once again highlighted the problem of error in healthcare.
Kevin Murphy died in September 1999, almost two years after he was found to have hypercalcaemia (an elevated level of calcium in the blood). Through an unfortunate series of errors, a definitive diagnosis was never made and treatment for the condition never implemented.
The series of events outlined to Mr Justice Murphy in the High Court formed a lethal chain reaction. Had any one of them occurred in isolation, it is possible Kevin Murphy would be alive today.
Murphy went to his GP in 1997 complaining of persistent pain in his spine. Tests found he had a high level of calcium in his blood. He was referred to an orthopaedic surgeon, who assessed him in November 1997. The specialist performed further blood tests which suggested kidney problems and confirmed the high levels of calcium.
The surgeon wrote to Murphy's GP recommending that he repeat the tests and that if the calcium levels remained high, he should be referred to an endocrinologist. The GP said he never received the letter. Crucially, the court heard, the results were never directly communicated to the patient.
Murphy's symptoms continued for a further two years and he returned to his local surgery, where a locum GP again ran a series of investigations. On the basis of the results the patient was admitted to Cork's Mercy Hospital in September 1999. But those blood test results were written on a Post-it note, which in turn was attached to the referral letter. The consultant under whose care Murphy was admitted said the note was stuck to the back of the letter. The crucial blood test results were therefore not seen until after Murphy died three days later.
Ernest Cantillon, solicitor for the Murphy family, told the court that independent experts had indicated there were a number of abnormalities in the blood results. They were of the opinion that the results suggested a diagnosis of primary hyperparathyroidism and a 50 per cent reduction in renal (kidney) function (see panel, right).
The problem of medical error is nothing new. The risks of the healthcare system were raised at a scientific session at the recent annual meeting of the Irish Medical Organisation (IMO). Dr Jesper Poulsen, president of the Danish Medical Association, said the health sector "is a very dangerous place" and is "much worse than we think" from the point of view of patient safety.
He outlined studies from the US, Australia, the UK, and Denmark, all of which indicated that about 10 per cent of patients admitted to hospital suffer a "serious adverse event". He defined such an event as "an undesired happening, causing patients to be harmed as a consequence of examination, treatment or care rather than by underlying disease".
The IMO meeting heard that when the Danish Medical Association assessed how dangerous healthcare was it came up with the startling finding that healthcare ranks with bungee jumping and mountain climbing in a hazard rating.
"Healthcare is an unsafe system but it would be much worse if not for the extreme vigilance of health sector staff," Dr Poulsen noted.
But because doctors and other healthcare workers are human, they make errors all the time. What they don't do is go to work every morning with the intention of making mistakes. Very few healthcare errors arise from malicious intent. Dr Poulsen made the point that error is an inherent part of human cognition.
"It cannot be eliminated but it can be compensated for," he said.
A reference to medical records by the Danish expert looks strikingly prescient in the light of the Murphy case. He noted that many healthcare institutions still contain "heaps of handwritten paper. They make information difficult to retrieve, even more difficult to share, and create dangerous transitions". Many of us associate danger with major operations or intensive-care units. What is significant about the Murphy case is its illustration of the dangers inherent in the transfer of patient information between general practice and hospital care.
Research into patient injury has established the following causes: human error; technical error; treatment complications; system breakdown; and communication error.
In Murphy's case, it is possible to identify human error as well as a system breakdown. Communication error, represented by the failure to tell the patient about the blood results and the letters about the patient not being received, also clearly occurred. One could reasonably criticise the system by which the referral letter to the hospital had test results added in the form of a stick-on Post-it note.
Much of the present work on the prevention of healthcare error focuses on changing systems in the knowledge that "to err is to be human". A resilient system is one that encompasses a continuous awareness of the possibility of human and technical error. It expects errors to be made and it trains personnel to anticipate and recover from them.
Dr James Reason, Emeritus Professor of Psychiatry at the University of Manchester, points to medical training as one of the reasons for error among doctors. In his opinion, this contributes to the problem by creating professionals who believe themselves capable of getting it right all of the time. Clearly, this attitude can lead to a dangerous mindset and indeed one that resists the development of systems designed to anticipate error as part of everyday practice.
A separate but nonetheless important principle emerged from the Murphy case: that patients must question doctors and others in the healthcare system. They should not be afraid to ask what their blood tests show and what the possible causes are of a particular result. It is essential for patients to look upon themselves as partners in consultations and in their relationships with doctors. The best, and safest, care takes place when, facilitated by a doctor's knowledge, the patient decides what to do in terms of the further management of a problem.
Hypercalcaemia, an elevated level of calcium in the blood, is a relatively rare condition which is often caused by hyperparathyroidism, an excessive production of parathyroid hormone. The tiny parathyroid glands sit on either side of the thyroid gland in the neck. Overactivity is most commonly due to the development of a benign tumour in one of the glands. This condition can sometimes run in families.
Hypercalcaemia may also be due to bone tumours or other cancers.
As well as resulting in excess calcium in the blood - which itself leads to dehydration, confusion and vomiting - the condition puts pressure on the kidneys to get rid of the excess calcium in the system. This in turn leads to the formation of kidney stones and prevents the normal functioning of the kidneys.
The treatment for a benign parathyroid tumour is surgery. For other causes the elevated calcium levels can be brought back to normal by using steroid medication.