A checklist provides a frame work and initiates brief discussion about the case, expected difficulties and plan of action to deal with complication or difficult situations.
In the previous article, we discussed about human factors as one of the most important reasons for errors. An individual is aware of his/her immediate surroundings but not about the larger surroundings. This is called as “situational awareness”.
A person may do his/her job diligently, but when it comes to synchronous activity of different departments or different persons there is always a potential for error. When two people with different background information start functioning together, there is bound to be a gap. When few actions, having no logical sequence, have to be done in synchronized manners, the chance of something getting missed is high. Think of a memory test where few different objects are flashed in front of you and you are asked to memories them. It is a high possibility that you may forget some of them, if not, you will not recollect them in the same order!
When checklists come into play
Checklists find their way in such situations. Actually checklist is not a new concept at all. Do we not make a “To Do list”? However, the institutionalization of the checklist has an interesting history. In 1935, U.S. Military had organized an exhibition cum-competition for aircraft manufacturers. Boeing, the famous aircraft manufacturer was also in the competition. Model 299 of Boeing was very advanced and could carry five times more bombs than expected by the US military. The competition was a mere formality by Boeing. Major Hill, a very experienced pilot and trainer was given the job to fly the aircraft on that day. Model 299 took off smartly. The aircraft reached the height of around 300 feet height and suddenly tilted to one side. Within few seconds it collapsed to the ground and caught fire. Major Hill lost his life. After this unexpected accident, a fact finding committee was constituted. The committee concluded that there was no technical fault in the aircraft. The pilot was at fault! How could an experienced pilot commit such a blunder? That took a blunder that could cost his own life? Later, it was realized that the systems of the aircraft were quite complicated. Actually, the pilot was supposed to perform a number of tasks within a small period of time in a synchronous manner. And Major Hill had simply forgotten to perform one out of them! Continue reading
Today’s medicine is like a double edged sword, it can benefit but also harm
In the last article, I wrote the story of Richie Williams and his doctor Dr Lee. Richie was wrongly injected vincristine intrathecally (in the spinal space). Richie lost his life. Dr. Lee committed suicide later. Both were the victims of medical accidents. The first victim was the patient and the relatives and the second victim was the doctor and other healthcare professionals.
Let us analyse the sequence of events. Why did such an error occur? Behind such incidences we always find the people involved. But why did these people make such an error? The science of patient safety states three main factors: the human factor, the system factor and, above all, the factor of the complex healthcare system.
Today’s medicine: a double-edged sword
When we see a picture of a doctor in the 18th century, we see a doctor with few things such as stethoscope, torch and a small bag of medicines. And we typically see a doctor holding the patient’s hand with empathy. Now let us imagine a picture of today’s doctor. What do we see? Big hospitals or clinics, nurses fluttering around in hurry, huge machines and then the doctor who is examining the patient using some device or gadget or reading some reports or looking at a computer screen. In fact, we can’t imagine today’s doctor working without reports, gadgets and the help of others. Continue reading
Richie Williams was young boy of 12. He was suffering from leukemia (blood cancer) and was undergoing treatment at the Great Ormand Street Children’s Hospital which specialised in treating such patients. Richie used to receive anti-cancer medicines in a cyclical manner. He used to go to the hospital on a pre-scheduled day to receive his dose of chemotherapy. They used to give him a dose of injection Vincristine by intravenous route. Another dose of injection methotrexate would be injected intra-thecally (injection between the spaces in the back bone, typically called as spinal injection). Being young, Richie used to get a small dose of sedative first and then the spinal injection would be given to him. He was doing well and recovering fast. In fact, he was almost at the end of the chemotherapy regime.
In the month of July 1997, Richie as usual went to the hospital. He was always instructed to come ‘Nil by mouth’ (empty stomach) to the hospital. On that day in the morning someone offered him a cookie. The young boy simply could not resist it and quickly ate it. Richie got admitted as usual to the chemotherapy ward. Dr. Murphy was on his morning rounds and saw Richie in the ward. Dr. Murphy was a senior doctor working at the hematology department of the Great Armond Street Children’s Hospital. “Hi Richie! How are you doing today?” he asked Richie. Continue reading
A message that goes in rounds on social networking sites reads as under:
“What is safer? Guns or healthcare?” The answer was “Guns”.
This followed a statistical explanation. “There are 700,000 doctors in the US and 100,000 medical mishaps take place every year. There are some 1,600,000 guns which lead to some 1,500 accidents yearly. And most importantly, the need for healthcare is unavoidable and absolutely necessary to every individual, whereas, guns are not essential for life!
This sound scary… doesn’t it? But it is the blatant truth! Healthcare is supposed to cure people, protect them from diseases and improve the quality of life. However, the same system, sometimes, causes harm to the patients. All the healthcare professionals in India will know of at least one incidence in which the patient was harmed. We read such horror stories regularly in the newspapers. But you will be surprised to know that medical accidents are happening all over the world, no matter whether the country is rich or poor, developed or developing, and whether it is the private sector or the government sector. Medical accidents and harm caused to the patients are a serious problem, realized by increasing number of healthcare systems across the globe. We have always believed that it is the carelessness and callousness of bad and incompetent doctors or healthcare professionals which is the cause of such unfortunate incidences or mishaps. We attribute such incidences to someone’s mistake, error or negligence. Continue reading
Everything went wrong in my surgery. I went through a horrible experience. No one, not even your enemy should go through such an experience ever. But I know for sure, the doctors were not negligent.
My mother, who herself is a senior specialist doctor in the western suburbs was narrating her experience of undergoing appendectomy, which went miserably wrong. She was speaking in a medical conference and sharing the horror story of her on experience. She tried to be composed and spoke in stern voice while tears were rolling out of her eyes. There was a pin drop silence in the auditorium and audience was stunned.
This incidence dates back to March 1999. My mother started getting severe pain in the abdomen. She figured out that that it might be an attack of appendicitis. Immediately, we took her to a reputed surgeon. The surgeon had been my mother’s colleague for many years and had operated on many of our relatives in the past. He examined her and confirmed, “Yes, you are right. This seems like an attack of appendicitis. We need to operate upon you.” My mother being a doctor herself had figured it out that it would in all probabilities turn out to be appendicitis. So she was ready. Continue reading