Published 15 October 2009, doi:10.1136/bmj.b4226
Cite this as: BMJ 2009;339:b4226

Editor's Choice

When things go wrong

The claim that "4% of human activity is error" may be one of those statistics made up on the spur of the moment, but it seems about right to me. Systems can be engineered to minimise the consequences of these errors—think aviation—but not to do away with them completely. The question for us is how best to handle the inevitable cock-ups that occur in the delivery of health care.

It goes almost without saying that the first step should be a comprehensive explanation of what went wrong, followed by an apology if warranted. And yet patients or their aggrieved relatives often complain to us that healthcare providers stick with misinformation and denial for as long as they can.

The most promising new development on this front in Britain is the increasing reporting of safety incidents to the National Patient Safety Agency (doi:10.1136/bmj.b4153). On the face of it, nearly half a million incidents reported over a six month period, contributing to 2000 deaths and 3700 cases of serious harm, hardly seems like cause for celebration. But it’s what’s being done with these data that deserves recognition. They are being synthesised into concrete recommendations and being fed back to healthcare staff. Later this year, we’ll begin publishing some of them as "safety alerts" in the Practice section of the journal.

For some patients and their relatives, explanation, apology, and the knowledge that attempts are being made to protect others from similar errors are not enough. They throw themselves into the willing arms of the media. This brings a new set of problems, at least for doctors. Patients can say what they like about their treatment; doctors’ duty of confidentiality denies them the opportunity to set the record straight unless they have patients’ express consent.

The General Medical Council recently reiterated its tough stance on this issue. As reported by Clare Dyer, its latest guidance on the topic says that doctors must not discuss an individual patient’s case without consent, no matter how "frustrating or distressing" it may be to have inaccurate or misleading details of a doctor’s diagnosis, treatment, or behaviour published (BMJ 2009;339:b4055).

Jack Gilliat strongly disagrees: "If a patient has discussed a part of his or her medical condition in the public domain and in so doing denigrated a doctor without justification, surely the patient has surrendered medical confidentiality for this part, and the doctor has a moral, if not a human, right to set the record straight as a matter of public record if the patient refuses to recant flagrant untruths" (doi:10.1136/bmj.b4173).

I incline more to Dr Gilliat’s opinion than to the GMC’s guidance: you can’t have one party breaching the confidentiality of a relationship while denying the other party the same right.

This journal gets things wrong, too. A fortnight ago we published an Endgames question that blithely mentioned the results of a lumbar puncture performed in the presence of a supratentorial space occupying lesion (BMJ 2009;339:b3940). Very bad (possibly lethal) practice—as almost every reader of this journal will know—and a point that was clearly made in the answer to the question. Dean Jenkins, director of BMJ OnExamination, from where the question came, explains the thinking behind its inclusion (doi:10.1136/bmj.b4185). And I can apologise to anyone who was misled. We’re sorry.

Cite this as: BMJ 2009;339:b4226

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