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How Mistakes In Hospitals Happen

Human errors plus system factors are all at play.

28/07/2016 12:00 PM AEST | Updated 29/07/2016 2:24 AM AEST
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Clerkenwell
"In the hospital, there are a large number of safeguards in place to protect us all."

Every day, in every corner of the world, things go wrong. Sometimes it's bad judgement, inattention or some other form of human error. Sometimes it's just bad luck. Whatever the reason, when things go wrong, people can get hurt or even die. When humans are involved, at whatever stage, mistakes and accidents happen and it is tragic for all concerned.

Hospitals are not immune to this. This week, we heard the tragic story of two babies in NSW who received nitrous oxide instead of oxygen during a critical moment. One baby unfortunately died as a result of this and the other has been left with permanent injury. When errors result in death, it is tragic. When the death is that of a child, the pain is felt so intensely and I cannot even begin to imagine what these families have gone through.

Errors in hospital receive a lot of attention. It is entirely understandable why. When we go to a hospital, we have an illness or an injury and we go to get better. The amount of trust that we place in our caregivers, the equipment, the infrastructure and the systems is immense. So when this trust is violated, be it through accident or error, emotions understandably run high.

In the hospital, there are a large number of safeguards in place to protect us all. For example, before you have an operation, we do something called a 'team time-out'. That's where everyone stops what they're doing and we check that we have the right patient, operation and side that they're having the surgery on, any allergies they have or any other special concerns.

In the event of an error or an accident, or even a near miss, we have reporting systems that can be made anonymously. This allows investigation of the systems in place, repair of equipment or further training for staff. This is a no-fault system, so as to encourage reporting of problems within hospitals so nobody feels scared to come forward.

Earlier this year, an article in the British Medical Journal received a large amount of attention when it claimed that errors in hospitals were the third leading cause of death. Closer examination of the data showed that this was, in fact, not quite accurate. However, the attention received is an important reminder to us all that we need to be vigilant and responsible as individuals but also that we need to have robust systems to try and negate the human factor.

A number of errors that happen in a hospital setting are related to medications and result in no actual harm. About one in 10 patients are subject to some kind of error in hospital. Around 40 percent of these are preventable. Fortunately, the rate of these errors leading to death is exceptionally low. On a numbers game alone, if you go to hospital, you are more than likely safe.

Errors that result in severe patient harm or death are actually decreasing as we improve our systems. The large and well regarded Western Australian Audit of Surgical Mortality (WAASM) actually demonstrated a 15 percent reduction in hospital deaths over five years.

So why do mistakes happen in hospitals? The reasons are vast and include problems with time, systems, equipment or resources. When you add these to the inevitable nature of human error in a system run by and maintained by people who are fallible, then errors will happen. We often refer to this as the 'swiss cheese effect'. Because of the safeguards in place, for an adverse event to happen, several things must happen together to result in an error, like the holes of a block of swiss cheese lining up.

I want every patient to know that health care workers, including doctors, are there to help our patients. We all struggle every single day with disease that is a taxing battle in itself and the last thing any of us want to do is bring further harm or distress to patients. It is a quality that is instilled in us all from the very early stages of our training in whichever field we are in. Losing a patient or seeing them have a complication is a hard pill to swallow, and the last thing we want to do is be party to that.

The difficulty is that it takes more than the integrity and hard work of our hospital workers. Outside contractors who build our hospitals, food suppliers who feed our staff and patients and so on, all contribute to patient safety. And again, human errors plus system factors are all at play.

In Australia, we are fortunate that we collect huge amounts of data that allow us to see where the system falls down. We have the ability to see where the holes in swiss cheese might line up to cause harm. This incredibly tragic case of the two babies in NSW is a horrific reminder of what is at stake and how important it is that we never stop improving things, never become complacent and always put our patients first.

Again, the loss of a loved one is a terrible thing to endure. The loss of a child is even harder and when that loss is from error, my heart breaks for these families. The community, hospitals, government and management must continue to make our hospitals as safe as they can be so that we keep the trust that we are so fortunate to be given.

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