Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Lack of Directors Accountability and Defensive Medicine are at the Foundations of Medical Errors
- Dan Michaeli (17 March 2000)
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Managing the risk of technology
- Stan Goldstein (20 March 2000)
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Time for no fault compensation?
- Tim Ballard (21 March 2000)
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To err is human, to ignore reality is bad science
- John P Heptonstall (21 March 2000)
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Re: To err is human, to ignore reality is bad science
- John F Morgan (22 March 2000)
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Re: Re: To err is human, to ignore reality is bad science
- John P Heptonstall (24 March 2000)
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Studying medical error in general practice
- Aziz Sheikh, Brian Hurwitz (28 March 2000)
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Patient Safety
- Victor Barley (18 April 2000)
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Beware: physicians at large!
- Tom Oommen (21 April 2000)
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Medical error non-existent in primary care?
- George Dowswell, Stephen Harrison (8 August 2000)
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Re: Medical error non-existent in primary care?
- Peter von Kaehne (9 August 2000)
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Tackling the "barriers of shame and punishment"
- Alex Gatherer (6 February 2001)
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Re: Patient Safety
- Graham Neale (22 April 2003)
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Dan Michaeli, Chairman, Board of Directors Clalit Health Services , Israel
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The Editorial certainly touches upon many important points and it is easy to agree with its contents. But I wish to underline two issues. The first is mentioned in the article, namely the responsibility of the directors. In this respect I believe the case of the Bristol hospital may signal an historical turning point. I believe that once Health-services Directors are really accountable for the medical performance of their institutions we shall find a rapid investment in many of the means mentioned in the article. The second point may be even more complicated. Many things have changed in the practice of medicine in the last decades.One is the result of the defensive attitude and behaviour of doctors. Litigation and the media may have helped in pointing to individual cases and the doctors involved were made to pay a certain price for their misdeeds. But the defensive behaviour of the Profession has devastating results. I wish torefer to two examples . One is the decrease in the number of autopsies performed and the second is the reluctance to conducting open discussions by the medical staff about mishaps. Mortality conferences as we knew them , at least in Israel, are disappearing, since everything said in these conferences may serve as evidence in Court against doctors. The Israel Medical Association have gone as far as signing a "Covenant" with the Ministry of Health which gives it a power to veto such inquieries and conferences that might jeopardise doctors. The case of the disappearing autopsies is not less dangerous. In the past we used to perform autopsies in more than 75% of deaths in the hospitals. We don't reach even 15%-20% today. Twenty years ago we studied posrmortem examinations performed during 10 years at the Sheba Medical Centre and found about 80 cases of active tuberculosis that were not even suspected when the patient was alive. Do we have any similar information today with the epidemic of AIDS ? The legal system must find a way to protect doctors who wish to uncover their failures candidly and not expose them to litigations. It is in the interest of the profession but it is also the interest of the public and the patients. I wish I could believe that we are ready to face these two challenges. |
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Stan Goldstein, Medical Director HCF Australia
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Dear Editor, Substantially reducing preventable medical error is an alluring idea, a new Jordan River to cross, and one behind which I would like to throw my full support. However, I am far from convinced that the promise of a technology solution to this vast array of problems is fair or realistic. The EMR has been tantalisingly 'close' for most of the last decade already. Work practices have been changed in many environments, and New Zealand, South Australia and even New South Wales all come to mind, but there is little or no evidence that better working conditions have been associated with greater safety for the patient - or perhaps even the opposite may be true. Clinical pathways and patient tracking and patient focussed care have all promised greater efficiency and less 'unnecessary variation', but looking at the various reports emanating from the US ("To Err Is Human"), Australia and elsewhere, one must be concerned. It seems the data is not simply recognition of a problem which, although large, has been put on the decline due to positive intervention on our part. I can't help but think that the problem is, if anything, worsening, despite our best intentions, and I have to wonder why this might be so. From my own observations in a number of large Teaching or Tertiary hospitals and some smaller ones, it is not just our 'systems' that are letting us down. In fact, the more systems I saw, the more I felt I was seeing doctors and systems and doctors within sytems, who were less and less able to adjust to variation which is the natural range of the patient condition, or to the as yet unknown diagnosis. Incremental change in our patient safety systems is both desirable and, I believe, unopposable. Even so, there may also be a need to re- engineer our entire thinking about how the health carers and the health care systems should be trained and structured in order to be able to work within a framework of better and effective patient safety. There is still no algorithm which has convincingly replaced for me the 'gut feeling' which was often the final arbiter on medical decisions, and no way of eliminating the variation in the style, personal traits, and recent reading of the clinician. These are inputs which are real and often proper, but which fall outside the usual parameters described by most systems solutionists. Taking a lead from Prof Wu, one can only hope that the proponents of the technological 'fix' will take care to assure that the clinicians can adjust and retain both interest and satisfaction, as well as the skills they need to feed their individual 'gut feelings', albeit in an informed manner. Let us move together towards a safe but exciting New World, and not just a Brave one. The former has greater long-term sustainability, in my opinion. Dr Stan Goldstein |
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Tim Ballard, GP Great Bedwyn, Wiltshire
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Dear Sir, I found the theme and content of the 18th March edition both a breath of fresh air and a challenge. I could not agree more that the errors that are made in medicine are often a final step in the delivery of care by complex organisations and that we currently work in an environment which does not foster error reporting. I also concur that to make progress there needs to be a change in the culture of medicine in the UK. The general press covered the content of this edition of the BMJ in a characteristic way declaring that "Doctors cannot admit errors"(Guardian 17/3/00). For error reporting to be a valuable tool in the provision of safe high quality care the culture change needs not only within medicine but across the whole of society. Society has a right to safe health care delivery systems but it also has a responsibility to provide the environment which facilitates this. Perhaps it is time to revisit the idea of "no fault compensation"? Tim Ballard |
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John P Heptonstall, Director of the Morley Acupuncture Clinic and Complementary Therapy Centre West Yorkshire
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Editor I agree with all commentators on the need and desire in Western medicine (WM) to reduce errors; I also believe that 'to err is human' and there must be a system whereby doctors can 'make honest errors' without punishment where recognition and rectification then takes place. From my perspective in 'Traditional Chinese Medicine' (TCM)I see patients who believe (and my own science would support their beliefs) that they have been damaged by WM not through error, or neglect, or pre- meditation but by bad science or non-science. So much of WM is unscientific or is forged out of theory or opinion; these tenets may be inherently dangerous with or without medical malpractise. None of the commentators mention such arguments, perhaps because of their inherent belief in the medicine they practise. Those of us who use TCM also follow a widespread medical culture that heals, and that can harm; we read and treat the body under different rules, our medical model has stood up for centuries; we read disease, and we recognise causes for much of that - epidemiology is an important aspect of TCM. I would say that WM-induced iatrogenic illness is far more common than perceived, and hence well hidden, such that reporters of 'medical error' are oblivious to it. It has been long acknowledged that the evidence-base (EB) for many WM interventions could be less than 20%, so 8 out of 10 precriptions may be without scientific validity! There are many reasons for this, not all related to bad science, but 'error' is not a major one. GPs may be under-reporting ADRs by 24,500 times, decimating statistics for iatrogenic illness (Moride Y et al., Br J Clin Pharm 1997 Feb;43(2):177-81. Many of these ADRs would be recognised as such by patients and their TCM practitioners. We spend much time recovering patients from WM iatrogenesis either through our interventions or by returning them to GPs for amended prescriptions. I'm sure that is one reason for the dramatic swing towards non-WM therapies seen this past decade. One needs to look critically at WMs basic 'science'; the constant application of interventions which are really theoretical practises without hard scientific validity; the generalisation of, instead of 'individualised', patient treatments and care; till then WM will continue to do much 'non-erroneous' harm. A few examples:- 1. children are medicated according to adult trial results
a. "cholesterol causes heart disease" so the public is mass-
medicated, to sustain a myth, and levels are reduced way below
'scientifically validatable' levels of danger.
Physicians must begin to INSIST that their interventions are evidence -based (EB), ideally RCT-based; for example, at present there appears to be very little RCT EB for any child prescription so why do doctors prescribe? If I were a commercial pilot I would INSIST that my aircraft was properly engineered and maintained, for the sake of my passengers. I would not pilot an aircraft thrown together on theory and opinion. Regards John H. |
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John F Morgan, Department of Psychosomatic Medicine St George's Hospital Medical School
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Sir I would be grateful if Mr Heptonstall could cite the reference from which he is able to state '"Prozac relieves depression" ... - invoking psychosis and suicide in large proportion of recipients (recent study in Wales suggests 10% of recipients may suffer serious adverse mental/emotional reactions).' I searched medline for 1999-2000 and could not locate the study from Wales, but medline is a notoriously inadequate device! If true, such an important finding would inform my clinical practice and surely deserves wider attention. Yours sincerely Dr John F Morgan |
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John P Heptonstall, Director of the Morley Acupuncture Clinic and Complementary Therapy Centre West Yorkshire
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Editor To 'inform Dr. Morgan's clinical practice and ensure wider attention'...I have located the following exerpts including the reference Dr. Morgan requested. I've transcribed from originals for ease of reference, though references are included:- 1. Anthony Browne, Health Editor, The Observer, Sunday March 12th
2000...."Clinical research soon to be published"...
2. The Guardian, Weekend, Sarah Boseley 30th October 1999 Saturday
( www.newsunlimited.co.uk/weekend/story/0,3605, 97667,00.html)
Finally Lipinski JF et al "Fluoxetine-induced akathisia : clinical and theoretical implications" J Clin Psychiatry Sep 1989;59(9):339-42 says that the estimates of actual share of Prozac users who suffer from akathisia is between 10% and 25%..( www.garynull.com/Documents/prozac1.htm). Regards John H. |
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Aziz Sheikh , Brian Hurwitz
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We welcome the BMJ's contribution to discussions concerning the study of medical error.1 Of concern however is that although the overwhelming majority of clinical encounters in the health service take place in primary care, almost all deliberations to date have focussed upon delineation of error in the hospital sector. Error in primary care is neither well characterised nor understood. As far as we are aware there are few, if any, initiatives designed to document its occurrence or determinants in general practice. One first step to begin study of error in this setting would be the creation of an error's log.2 If based on a voluntary, confidential, self- reporting scheme, akin to logs used by the Federal Aviation Authority, this would enable systematic study of medical error without fear of reprisal.3,4 Funded and administered at Primary Care Group level, within the context of clinical governance initiatives, such logs would enable patterns of error and latent deficiencies in service organisation and delivery of health care to be identified, including those that place patients at risk of avoidable harm. Though doubtless subject to under reporting bias, such a move would help to bring error out of the shadows of secrecy and blame and into the light of systematic description and study. References 1. Leape LL, Berwick DM. Safe health care: are we up to it? BMJ 2000;320:725-26. 2. Sheikh A, Hurwitz B. A national database of medical error. J Roy Soc Med 1999;92:554-55. 3. The Federal Aviation Administration Aviation System. http://nasdac.faa.gov/safety_data (Accessed January 2000). 4. Cohen MR. Why error reporting systems should be voluntary. BMJ 2000;320:728-29. Aziz Sheikh
Brian Hurwitz
Department of Primary Health Care & General Practice, Imperial College School of Medicine |
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Victor Barley
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Editor - It was brave to devote a whole issue to medical error (1) - how to recognise, how to investigate, how to analyse and how to change systems to improve patient safety. However, we regret that the edition was dominated by American studies, ignoring the British contribution of 'confidential enquiries' and analyses of 'closed claims' which have significantly improved safety in some well-defined areas of medical practice. In the US the insurance industry provided the impetus for the study of adverse events(2) and in Australia the government funded a similar study(3) because it was considering 'no fault' compensation. In the UK for 25 years the Department of Health has financed all successful claims against NHS hospitals and their staff. As a result the need to take a British study beyond the pilot phase may not be supported(4). Be that as it may an important issue was not addressed in the BMJ. Behind each adverse event there is a patient, a doctor and a doctor-patient relationship. A patient must be told when things have gone wrong. Every effort must be made to minimise the after-effects including financial compensation where necessary. Most patients wish to know in detail what happened and what is being done to reduce the possibility of a recurrence. And members of health care teams need mechanisms to come to terms with their fallibility. It is to be hoped that clinical governance will make a difference. Meanwhile a change in the ethos of medical practice is required and it is to this end that Action for Victims of Medical Accidents (AVMA) has set up a Doctors' Group. AVMA is often regarded as dealing solely with compensation and litigation but its raison d'etre has always been to improve patient care. On 8 February the Doctors' group met informally to discuss how best to translate into practice the GMC's requirements of 'good medical practice when things go wrong'(5). We are determined to take our discussion forward and would welcome input from others who see the need to change the defensive and exclusive culture of British medicine. Doctors who would like to be involved should contact Dr Anne Savage who is acting as secretary to the group. 1 British Medical Journal No 7237. Reducing error: Improving Safety. BMJ 2000;320:725-814 2 Brennan TA, Leape LL, Laird NM, Herbert L, Localio AR, Lawthers AG, et al. Incidence of adverse events and negligence in hospitalised patients: Results of the Harvard Medical Practice study. N Engl J Med. 1991;324:370-6 3 Wilson R McL, Runciman WB, Gibberd RW, Harrison BT, Newby L, Hamilton JD. The quality in Australian Health Care study. Med J Aust;170:458-71 4 Smith J Study into medical errors planned for the UK BMJ 1999;319:1091 5 Good Medical Practice. General Medical Council London 1995 ( www.gmc-uk.org) Victor Barley |
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Tom Oommen, Associate Professor of Pharmacology Fr. Muller's Medical College, Mangalore, India
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Do systems change to improve patient safety? I wish they really did. If, as Leape and Berwick (1) say, systems change to improve patient safety, what is the system that operates in India during episodes of overinvestigation of patients, who may end up being asked to consider having coronary bypass surgery when the presenting problem is really something like a urinary tract infection? First, there is the system of the mutual admiration society, where physicians tend to enlarge their businesses by encouraging their peers. Then there is the system of channel practice where the physician insists on a second opinion from one particular consultant only, usually that one being the same person who refers patients back to him. Laboratory tests are requested from only certain laboratories from where kickbacks are received. Then there is the system where only certain forms of therapies are validated for reimbursement of medical expenses by the HMOs. A fourth system is that which is insists on the latest equipment and lab tests being done for even trivial symptoms under the pretext of avoiding action being taken against the doctor by the consumer protection forum. And a final system of the health care is the one which believes or makes believe that the super specialist is the one who is always correct, thereby permitting him to call the shots and use his special knowledge to monopolise the situation, play God. All these are real systems that operate simultaneously, concurrently and perhaps in perfect harmony to such an extent that it becomes virtually impossible to change any one of them. If the medical profession to improve patient safety, perhaps the best policy would be to ban privatisation of medical practice. Medical practice would then become uniformly administrated all over the country and the risks of systems operating within systems or wheels moving within wheels would be minimised. Reference: 1. Leape L and Berwick D. Safe health care: are we up to it?. Editorial, BMJ 2000; 320: 725-726 |
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George Dowswell , Stephen Harrison
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Your special edition on medical error 1 drew attention to the need for organisations to create environments "in which it is 'safe' to admit error and safe as well to explore why the error occurred." 2 It was notable that all but one of the articles 3 related to hospital settings and yet it is unlikely that primary care is error free. Thus, the question arises of whether General Practitioners (GPs) have safe systems to deal with error. Our ongoing interview study with a random sample of 49 GPs, primarily exploring the uptake of clinical practice guidelines, included specific questions about the organisational culture and information processes in the practice contexts. Most GPs (40;82%) believed they could openly discuss areas where their practice was uncertain and 43 (88%) reported that they could ask colleagues for information if they were uncertain about practice. However, only 26 (53%) thought that their practice had a method for addressing areas where practice was uncertain. Less than half (20;41%) met regularly to formally share information about medical developments but 34 (70%) informally discussed medical developments with colleagues within the practice. Twenty seven (55%) were able to discuss medical developments with colleagues outside the practice. Over half of GPs (28;57%) believed that they share similar views about the process of integrating research into current practice as their colleagues. Only a fifth (10;20%) reported that they used peer review to identify areas of weakness but the majority (37;76%) agreed that all of their colleagues admit to making mistakes. Of the twelve GPs who thought their colleagues did not admit to making mistakes, five were single handed and the other seven worked in practices of four partners or more. Larger practices met less frequently, (Chi squared 4.544; df 1; p<.05) which may have implications for cultural or procedural change. In conclusion, errors appear to be prevented and addressed in primary care more by luck than by management. Most GPs seem to have informal means of dealing with uncertainty and error. However, the largest and smallest practices may not provide the 'safe' environments or formal structures which are conducive to improving practice. 1 Leape LL, Berwick DM. Safe health care: are we up to it? BMJ 2000;320:725-6. 2 O'Leary DS. Accreditation's role in reducing medical errors. BMJ 2000;320:727-8. 3 Weingart SL, Wilson RMcL, Gibberd, RW, Harrison B. Epidemiology of medical error. BMJ 2000;320:774-777. George Dowswell PhD, Research Fellow Stephen Harrison PhD, Professor of Social Policy University of Manchester, School of Social Policy, Williamson
Building, Oxford Road, Manchester M13 9PL. |
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Peter von Kaehne, Gneral Practitioner Springburn Healthcentre,Glasgow
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Editor, I am somewhat taken aback by Dowswell and Harrison's rather pessimistic conclusion to their own study. "In conclusion, errors appear to be prevented and addressed in primary care more by luck than by management. Most GPs seem to have informal means of dealing with uncertainty and error." Following the thread of the previous debate in eBMJ it seems to be that the lack of an open atmosphere in which one can admit one's mistakes is one of the biggest obstacles to any learning from one's mistakes. Dowswell and Harrison's study seems to show that most GPs in the study have ready access to colleagues whith whom to discuss problem cases and mistakes. This access does not seem to depend on particular management systems, meetings and other formalisms. It rather seems to depend on mutual trust, respect (and possibly friendship) - an open atmosphere. Many GPs seem to have succeeded acc Dowsell and Harrison to create such an open atmosphere in their work environment. To call this "luck" seems to be somewhat demeaning. It propably required a lot of hard work over many years. Coming from a different medical system and culture I have found it an enormous relief to be able to admit freely to my colleagues (medical and nursing) when I did not know what to do and/or when I felt I had done a mistake. The informal way this was handled helped a lot to lower anxieties and to learn from the experiences. To be able to chose to whom to talk also helped a lot. I do not think that the NHS is "the envy of the world", there are far too many short-comings, cultural and financial, but I do admire the fair and open way many British doctors are able to deal with their own and their colleagues mistakes and shortcomings. I would find it sad if this openess and trust gets replaced by yet another attempt of "management" |
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Alex Gatherer, Honorary Director, Oxford Centre for Medical Risk Studies Socio-Legal Studies, Wolfson College, Oxford
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I fully support Donald Berwick's call for a "commitment to change" but I cannot help wondering how this can be encouraged. In their excellent leader last year (BMJ 2000;320:725-726 (18 March)), Leape and Berwick include the point that "when the barriers of shame and punishment are removed" health staff eagerly work to improve safety.However much we redesign, these barriers will remain. We must surely include in the debate just how best these barriers can be tackled. Have the Scandinavian countries,with their types of no-fault compensation, got useful lessons for us? |
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Graham Neale, Medical tutor Clinical Skills Unit UCL, Rockefeller Building, 21 University Street, London WC1E 6JJ
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EDITOR - 3 years ago you published our letter(1) in the BMJ calling for a change in the defensive culture of British medicine. We asked doctors to express their interest by contacting the Action for Victims of Medical Accidents (AVMA) doctors' group. Progress has been made. The position today and pointers for the future are to be outlined at an important conference: "Safety First: Protecting patients, Supporting doctors"
For details contact Laura Milne, Academic Department, Royal Society of Medicine, London W1G 0AE (Tel: 020 7290 3942 E-mail: quality@rsm.ac.uk). Dr Graham Neale (deputy chairman, AVMA) 1. Barley V et al. Reducing error, improving safety. Defensive culture of British medicine needs to change. BMJ 2000; 321: 505. Competing interests: None declared |
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