Wednesday, 29 August 2012

Recurring 'errors', learning and some fundamental issues

Recurring errors

Many of you could be familiar with the Elaine Bromiley case where a young lady for a routine ENT procedure died due to intubation difficulty ( There it was found that there was lack of situational awareness, poor decision making and poor leadership. This happened in 2005.The Harmer report on the tragedy is dated July 2005, the coroner inquest in October 2005. Marin Bromiley, Elaine's husband, an airline pilot, chairs the CHFG to promote human factors with a view to reducing avoidable errors.

Gordon Ewing died in May 2006 and the Scottish Sherriff’s fatal accident enquiry determination has been published ( I recommend that all of us read all the 108 pages patiently. Here the patient was scheduled for open reduction and internal fixation of terminal phalanx of little finger and died due to airway related difficulty.

Again, similar factors such as poor decision making and poor leadership has come up along with a host of other factors. The unwillingness to stop has been a common factor in both cases. I suspect it is just not these cases.

The link below is about 3 post cholecystectomy deaths in a 3 month period in 2006

I feel that recurrence is probably an essential feature of an error, my guess is that there are no errors that have ever happened only once. It might have happened only once to a person or a location but the error itself would have happened a number of times. Vincristine and nuclear leaks come to mind.

Who should learn?

In meetings where we discuss morbidity, mortality and learning from SUIs, a phrase you might often hear is 'for the benefit of the juniors/residents/trainees', as though 'seniors' do not commit 'errors' or have nothing to learn from the discussion. Well, all the above cases are about very senior and experienced doctors; so these reports are not for ‘the benefit of the trainees’ or ‘for the benefit of the juniors’. It is for everyone, specifically for senior post holders. Also, though the specific examples are about anaesthetics, surgery, etc; these cases are not about anaesthetists, surgeons, etc; the lessons are for all of us clinicians and non-clinicians; the generic issues are relevant as lessons for everyone. Techniques are speciality specific and person specific, errors and learning are generic.


Elaine Bromiley's case is well known and is full of learning which have been described by many before.

In the Ewing case, the Sheriff says:

‘While the lead clinician has the over all responsibility to ensure safe use of equipment, individual clinicians have a professional responsibility to use only equipment with which they are familiar and competent to use. This is particularly so where the piece of equipment is rarely used.’

There are many gems in the Gordon Ewing report.

In the gall bladder surgery cases, the report speaks about:

Tunnel vision

Damaged confidence from an incident preventing speaking up at a subsequent incident, potentially causing harm.

Poor notes, missing notes

Breast surgeon doing cholecystectomy

Consultant surgeon not attending

Consultant radiologist refusing to do scans at night

Consultant surgeon who does not do lap cholecystectomy dealing with complications of cholecystectomy

The repeated failure that patients post operative problems could result from the surgical procedure

The report is very recent. The incidents happened not too long ago either. They are from a normal hospital with normal people like you and me working in it and dealing with typical/usual patients.

The learning is profound, not new - many of us would have faced these situations a number of times; errors are recurrent. The impact of errors are horrendous for the people involved in it especially for patients and families (see previous blog on impact of complications

Fundamental issues

It is very heartening to note that courts and authorities who write the reports use a very respectful language towards doctors. They limit themselves to investigating and reporting event, post-event and agree with the given wisdom in practise as acceptable standards. I wonder whether this prevents an exploration of some fundamental issues.

Let me ask an awkward question. Why is a general anaesthetic even an option to deal with the terminal phalanx of the little finger? The report says that there was no record of non-GA options. My point is not that, my question is why was GA ever an option. Some of you are going to leap up and say 'patient choice' meaning that patients have to be offered a choice or patient choice to have a GA must be agreed with. Patients choices are mainly guided by their clinicians views, supplier induced demand, often felt to be well meaning, is alive and well in healthcare.

I know a general anaesthetic is routinely one of the anaesthetic options for any surgical procedure; but so was Halstead's mastectomy for any breast cancer in the past. Would we offer it as a choice now? Hypothetically if a patient wanted a Halstead when a local excision would suffice, would we do it? When an easier, safer, quicker, better, cheaper method is available is it still valid to offer potentially high risk complex procedure as an option?

Here is another awkward question. Why are breast surgeons, colo-rectal surgeons and all surgeons doing gall bladders and hernias when hernia surgeons do not do breast or colo-rectal surgery? I do not mind good old style of general surgery where everyone did everything - at least that is what they were supposed to do.  But that is not the world we live in these days (even in 2006) at least in the western world in the era of sub-specialisation. The situation of anyone doing the so called 'simple' things, still persists in many hospitals. Toe nail problems are as profound as any other 'major' medical problems for that given day for that given patient; it is not a matter of scale or judgement.

I wish the various authorities recognise the need to ask very deep and fundamental questions. Such as was this really indicated in the first place? Were the right people dealing with issues to begin with? I wish they would not accept given wisdom based on pacts of convenience as acceptable. Not with a view to punishing but with a view to improving clinical quality.

I wish they recognise and point out that these are massive system and leadership failures.

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