"'The person most likely to kill you is not a relative or a friend, or
a mugger or a burglar or a drunken driver. The person most likely to
kill you is your doctor."
=== (Vernon Coleman) author, What Doctors Don't Tell You
Why do doctors kill more people than airline pilots?
Mistakes are buried - along with the patients -
How can it be made safer?
By Dr Phil Hammond
Last updated at 7:54 AM on 05th August 2008
Each year thousands of hospital patients die as a result of human
error. In a new Radio 4 programme GP Phil Hammond -who exposed the
Bristol babies heart scandal in the 1990s - examines whether enough is
being done to protect us.
Dr Phil Hammond: Questions who is to blame when patients die
The late Dr Tom Chalmers, a distinguished medical researcher, once
asked why doctors kill more people than airline pilots.
The odds of dying in hospital as a result of human error are 33,000
times greater than the risk of dying in an air crash - an
extraordinary figure, especially as most people are more scared of
flying.
Dr Chalmers came up with a number of reasons for this apparent
discrepancy - such as the requirement that pilots take time off for
sleep, undergo random breath-testing and that their skills are tested
every six months.
But he saved his harshest comment until last: 'If doctors died with
their patients, they'd take a great deal more care.'
Most doctors bristle at the suggestion that they don't take patient
safety seriously enough. After all, medicine is more complicated than
aviation and it's impossible always to get it right. Even the best
doctors make mistakes.
Errors happen either because we do the wrong thing (make the wrong
diagnosis or give the wrong drug) or we do the right thing wrong.
Often, we blame 'the system' for causing errors - the lack of manpower
that leaves exhausted and inexperienced staff without supervision -
but errors can happen in ideal cir***stances.
Take the story of Elaine Bromiley. Elaine was 37 when she was booked
in for routine sinus surgery under general anaesthetic. Her
anaesthetist had been a consultant for 16 years, her ENT surgeon had
30 years under his belt. The theatre was well equipped and there were
no emergencies elsewhere.
As her husband Martin observed: 'This was a dream scenario for safety;
a senior surgical team working undisturbed in state-of-the-art
surroundings.'
And yet Elaine's anaesthetic went tragically wrong and repeated
attempts to ventilate or to intubate - pass a tube into her airway -
failed.
'Can't intubate, can't ventilate' is a rare but recognised emergency,
which requires an emergency tracheotomy, cutting a hole in the throat
to pass the tube through.
However, the consultants decided to keep attempting to intubate,
finally abandoning the procedure hoping that Elaine would wake up. She
never regained consciousness and died 13 days later.
Martin Bromiley was initially told that his wife's death was bad luck.
But as a pilot, used to analysing critical incidents, he wanted to
hear the results of the ensuing inquiry.
Bromiley insisted on an independent review which concluded that, given
the experience of the surgeons, it should have been possible to follow
the emergency protocol and perform a tracheotomy. So why didn't it
happen?
Surgery safety: Deaths can occur during routine operations due to
human error
Errors happen not just because of lack of skill or knowledge but for
behavioural reasons. Put someone in an extremely stressful situation
and even the most senior clinicians can lose the plot.
The role of these human factors in error is well recognised in
aviation and Bromiley recently founded a charity to help health
professionals make better decisions under pressure.
What is needed is a team culture where even the most junior member of
staff can raise concerns.
Bromiley's inspirational approach -wanting us to learn from his wife's
death - contrasts with my aggressive exposure of medical scandals.
In 1992, I published confidential audit figures from Bristol Royal
Infirmary showing that its results for complex heart surgery on
children were very poor.
The Department of Health knew about the results in 1988 but didn't
step in until 1995.
I thought my articles would at least spark an investigation, but the
surgeons carried on for another three years until the death toll was
too high to ignore.
A subsequent public inquiry concluded that, between 1991 and 1995, as
many as 35 children under the age of one died who would not have done
if they'd been treated elsewhere.
The surgeons were enraged at having their audit figures published.
They didn't stop and reflect. They adopted a siege mentality and
carried on regardless.
Defensiveness was culturally ingrained. I trained during the days when
junior doctors clocked up 120 hours some weeks. The NHS paid lip
service to safety and junior surgeons were often left to perform
complex operations for the first time alone.
Mistakes were buried - along with the patients - and you muddled along
doing your best. There were huge variations in quality and thousands
of avoidable errors across the whole of the NHS.
It took the Bristol Inquiry to force politicians and the medical
establishment to take safety seriously. This sparked a sea change in
accountability, including the setting up of the National Patient
Safety Agency to monitor and learn from errors.
But has all this made the NHS safer? In parts, yes. Bristol has become
one of the safest places to have heart surgery. And the publication of
outcomes for heart surgery across the NHS has coincided with a
reduction in death rates.
But doctors in other specialties have been slow to open themselves up
to scrutiny. As a result, patients aren't as safe as they should be.
How can it be made safer? During the making of the Radio 4
do***entary, all the NHS staff I spoke to were passionate about
patient safety, but said a culture of blame and exposure was its
enemy.
Errors will inevitably occur, but what staff need to prevent these
happening again is time and sup****t to understand and learn from
them.
Learn from near misses
This approach doesn't excuse negligence - but often disasters happen
because of a chain of contributory factors, rather than the single
action of one person.
One of the pioneers of a more open approach is the surgeon (and Health
Minister) Lord Darzi.
Ten years ago, Darzi decided to introduce a black box in his operating
theatre at St Mary's Hospital, London. This recorded the patients'
vital signs, the anaesthetic procedures and, contentiously, the
surgical team, on video, as it went about its business.
Initially, he too struggled against the defensive culture: within 24
hours, someone had put bin liners over his cameras. But the black box
remains.
His colleagues now realise that the recorded information allows them
to learn from near misses so tragedies are avoided.
Darzi has also developed a simulated operating theatre that teaches
his team to manage common distractions (e.g. constant interruptions
during surgery) and rare, life-threatening emergencies.
Pilots are legally obliged to spend 16 hours a year in a simulator,
proving their competence, but for surgeons and anaesthetists, it is
still optional.
Darzi is also helping to pioneer a surgical checklist with the World
Health Organisation to ensure patients are given the appropriate drugs
and that everyone is prepared for what might go wrong.
This also encourages staff to speak up. However, for the NHS to
embrace safety requires the political recognition that it's not about
waiting lists and how quickly you get treated that matters, but how
safely.
Safe staff re****t more errors
One in ten patients admitted to an NHS hospital is accidentally harmed
- and for one in 300 patients, medical error results in death - yet
still not everyone accepts change.
Some doctors think checklists reduce them to factory workers, others
have a tantrum if someone reminds them to wash their hands. Safe
hospitals tend to be calm ones, where everyone accepts feedback and
works in a team.
Safe staff also tend to re****t more errors. The hospital that admits
to nothing generally has the most to hide.
So can patients do anything? In America, the error rate is lower than
in the UK. Doctors, ever wary of litigation, take safety seriously and
patients join in.
There, patients are encouraged to ask about a surgeon's training and
success rates, query medication, insist on hand wa****ng and ensure the
nurse has read their ID bracelet.
In the UK, we lie back and take it. It's far easier to trust
professionals. I've never met anyone who knocks on the cockpit and
asks the pilot how often he's landed the plane - you assume he's
competent, because he's still alive.
If Darzi gets his way, one day we may be able to take safety in the
NHS as a given. But not yet. So keep your eyes peeled and keep asking
questions.
TO ERR IS HUMAN is on Radio 4 on Monday, August 11, at 9pm.
http://www.dailymail.co.uk/health/article-1041663/Why-doctors-kill-people-airline-pilots.html
IN AMERICA: The American people do not enjoy good health, compared
with their counterparts in the industrialized nations......Even more
significantly, the medical system has played a large role in
undermining the health of Americans. According to several research
studies in the last decade, a total of 225,000 Americans per year have
died as a result of their medical treatments:
http://www.health-care-reform.net/causedeath.htm
http://www.whale.to/a/smith25.html
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