Table of Contents

“TO ERR IS HUMAN”
Dr. Ravindran Jegasothy
Councillor, Malaysian Council on Healthcare Standards

To err is human is the title of an Institute of Medicine publication that set forward the Goals of Medicine in the forthcoming years. It is an appropriate heading to reflect the notion that doctors are not infallible. It is another way of saying that “Doctors are not Gods”.

Medical errors or mistakes are inappropriate diagnosis, interventions, investigations or management that results in an adverse or unwanted outcome for the patient.

Negligence would be an adverse outcome that resulted from the practice of the doctor which does not measure up the standards of the general body of doctors. To prove negligence, it must be shown that there was harm to the patient caused by an inappropriate intervention or management that would not normally be done by the doctor’s peers.

All doctors make mistakes, some of which have consequences. Our natural inclination is to try to conceal them and forget about them. McIntyre and Popper (1983), however, recommend that we should make a determined effort to recognise and learn from them as they are convinced that knowledge grows more by the recognition of errors than by the accumulation of facts. Consequently, they consider that learning from our mistakes should take precedence over the acquisition of new information.

The 19th International Conference of ISQua held in Paris from 5th to 8th November 2002 had many sessions focussing on measuring adverse events, iatrogenic injuries and risk management. There is much that can be done in this country to reduce these events and lessen the harm that is caused to patients.

Frequency of medical mistakes

It is impossible to estimate the frequency of medical mistakes, but there can be no doubt that mistakes are much more common than most of us realise. The protection societies have information on the annual rate of claims and complaints, but this represents only a fraction of the total number of accidents.

The only published information currently available comes from the USA. A study conducted in California in 1974 (Smith, 1986) concluded that 3 million hospital admissions led to 140,000 injuries, giving an incidence of 4.7%. A more recent review (Harvard Medical Practice Study, 1990) conducted in New York State concluded that 2.7 million hospital admissions led to 98,000 adverse events, giving an incidence of 3.7%. With 5 million hospital admissions year in England alone, this might mean almost 200,000 medical accidents in English hospitals.

We now have some British date from London based on retrospective record review. In their study of over 1000 records in two acute hospitals, Vincent et al found that almost 11% of patients experienced an adverse event, over half of which were deemed preventable judged by ordinary standards of care. More worrying, at least a third of these events led to disability or death. This was a pilot study but there is no reason to believe that the results are unrepresentative.

There are no firm statistics on the matter in Malaysia. From our knowledge of complaints that are brought to the attention of the MMA, there are about 20-30 allegations of negligence per year. We must remember that there are millions of patient-doctor encounters per year in the private and government sector per year. There are about 120 medicolegal matters involving the Ministry of Health over an 8 year period. There are no public statistics on matters that are referred to the medical defence organisations. Looking at the figures and putting things in perspective, it would be wrong to say that serious medical errors occur often in Malaysia.

There have been no studies specifically on medical errors. However, there are two ongoing audits which provide some data. The Confidential Enquires into Maternal Deaths has been ongoing since 1991. It covers all maternal deaths that occur during pregnancy, childbirth and puerperium in the government and private sector. The deaths are investigated in an anonymous, non-punitive way. It is noted that in about 40-50% of deaths there was an element of remediable factors i.e. the patient could have been managed in a better, more appropriate fashion. It does not mean that the death could have been averted as there are many other factors involved. The Perioperative Mortality Audit covers operative deaths in government hospitals and similar findings are noted. These findings have been used in ongoing education of doctors. All private hospitals will be required to form mortality assessment committees under the Private Hospitals and Healthcare Facilities Act 1998.

The MSQH should support a scientifically designed study on medical errors. To reflect accurate figures, such study should ensure anonymity and be non-punitive. The conference indicated that a prospective study would be preferred for better reliability although the cost of such a study would be 20-40% higher. In some examples of studies presented, wrong site surgery, suicides in patients, patient falls and medication errors were some of the mandatory events that needed to be recorded.

Mistakes do not necessarily indicate negligence

Most medical accidents are due, in some degree to error, even if it is only a failure of anticipation. But most errors do not involve actual negligence (Vincent, 1989). The most conscientious doctor may make a mistake through ignorance or inexperience. In the study from California, quoted above, only one in six of the injuries were classified as being due to negligence; in the study from New York State, less than a quarter were due to negligence.

Mistakes in diagnosis

Doctors make mistakes in diagnosis, treatment and prognosis. The most important mistakes are those in which the diagnosis of a serious disease was missed or which the wrong treatment was applied. If the disease is acute, the mistake may be rapidly fatal. Fortunately, this is not often the case. More often, the doctor has an opportunity to revise his diagnosis and apply the correct treatment in time to avoid permanent damage.

Diagnosis may be delayed because the significance of the signs and systems is not appreciated when the patient is first seen. When this happens in a patient with cancer the possibility of cure may be lost. Sometimes a diagnosis is delayed because, although the essential information is available, a key report remains unread or unappreciated. This applies particularly to radiologists’ reports and those on cervical smears.

Mistakes in management

The wrong treatment may be given through ignorance or carelessness. Some mistakes simply reflect the ignorance of the day. Fifty years ago it was widely accepted that premature infants should be treated with high concentrations of oxygen. Now it is recognised that such treatment contributes to retinopathy. The history of medicine is littered with discarded treatments.

In the past, patients have been entered for research projects without their consent. Most came to no harm, but a few were injured as a result. Since this misconduct was exposed and ethical committees were established in all medical institutions, this practice has become much rarer. It would, however, be unduly optimistic to say that it has been completely abolished.

Prognosis is a very much difficult art, and every doctor makes mistakes in it, particularly at an early stage in his/her career.

Reasons for mistakes

The commonest reasons for medical mistakes are ignorance, errors of judgement and carelessness. Ignorance is, to some extent, inevitable. Even the most erudite and experienced doctors have large gaps in their medical knowledge. Knowledge is advancing so rapidly that no doctor can know everything, even in his own specialty.

Many mistakes are due to inexperience. The doctor may have up-to-date book knowledge but may never have seen some of the diseases that he is called upon to treat or may be forced to undertake a risky procedure without supervision. Or he may be a well-informed specialist in one branch of medicine, but with little experience of a disease in another specialty, which affects his patient. Some doctors are adventurers and are happy to attempt techniques in which they are inexperienced, without adequate supervision.

Errors of judgement are also inevitable. Medical diagnosis and treatment is not an exact science. There are always a number of imponderables in every situation. Every patient acts and reacts differently. Experience helps, but even the most experienced doctor is liable to misjudge a situation.

Occasional carelessness is universal, since doctors are human. Carelessness, in the broadest sense, is probably an important factor in medical mistakes. There is a good deal of truth in the saying “More mistakes are made through not caring than through not knowing”. There is a tendency in all of us to put personal comfort before patient care (Lancet, 1979). Family or business matters at times, distract all doctors. Some are constitutionally more considerate and careful and obsessional than others. Doctors should be aware of the risks involved in giving casual medical advice to a friend.

No consideration of reasons for medical mistakes would be complete without mention of organisational and environmental factors. An important measure that the MMA has taken is to fight for improved working conditions of doctors especially in the government sector. The tired, overworked doctor is more prone to mistakes. To be fair to the government sectors, there have at the forefront of quality improvement activities to reduce medical errors.

There are undoubtedly important. Doctors make more mistakes when they are tired and rushed, because there is a tendency to cut corners. But we must resist the temptation to put all the blame for our mistakes on ’the system’.

Avoidance of mistakes

Every doctor should make it a matter of honour to keep abreast of the advances in medical knowledge in his specialty, and also the major advances in other specialties. Ideally, he should not undertake any work for which he is not equipped or in which he has no experienced colleague to consult. This is, of course, counsel of perfection, because occasionally a doctor may find himself out of his depth though unforeseen circumstances. He has no one to turn to and has to do the best he can.

Doctors can avoid mistakes and learn to correct their individual bias by consultation with colleagues. Ward rounds with other colleagues as well as with our junior staff, help to pool our ideas about the diagnosis and treatment of the more complex problems we encounter. Another educational practice is attendance on the ward round of other consultants.

Learning from mistakes

If McIntyre and Proper (1983) are right, and knowledge grows supremely from the recognition of errors, how can we do this in practice? Obviously, we need to keep good records, and do out best to follow up our problem patients. Without accurate records, it is impossible to know how often we are mistaken in our original diagnosis.

The MSQH should view medical mistakes seriously. It should acknowledge medical mistakes are made. MSQH stresses the importance of continuing medical education of the profession in order to reduce mistakes due to ignorance or inexperience. It promotes the accreditation of hospitals and clinics in order to ensure quality assurance procedures are in place. It supports transparency in acknowledging mistakes by subscribing to the belief that quality assurance indicators of hospitals should be in the realm of public knowledge.

What can patients do to reduce the likelihood of medical errors? Patients should be fully informed of the nature of their illness and options of treatment. Patients should also have realistic expectations after seeing a doctor. They should not expect a full recovery in all cases. It is the duty of doctors to inform them of this. Patients should also ensure that they see appropriately trained doctors for their particular illnesses. It is best that their family doctors for accurate information.

Should a patient suspect that there had been medical negligence, what is the next course of action? It is best that they see the doctor for a detailed explanation and clarification. Many doctors would be quite willing to see them. Many would be quiet happy with the explanation and the matter would stop there. The patient can also request for a medical report and use this to seek a second opinion from other practitioner. Some may then seek legal opinion.

Suggested remedies to avoid medical errors

What can be done about these errors? They cannot be ignored. Once errors are recognised their causes must be analysed so that preventive measures can be applied. Some of the mistakes are caused by systems failure. This has been shown, for example, with drug errors or wrong transfusions. Clear definition of clinical responsibilities is need. Fatigue may also cause problems, as does the use of inappropriately junior staff. The main causes of adverse events relate to operative errors, drugs, medical procedures, and diagnosis. Each of these is amenable to prevention. Better surgical training is obvious. This has been taken on board by the Royal College of Surgeon, though concerns remain that, because of shorter training and tighter working hours, young surgeon are less experience than previously. Better training programmes will also help with medical procedures. Fewer operations and procedures during the night may also help. Drug errors remain a problem no one can remember all the possible drug interactions that may occur, and incorrect dosages are also a recurrent problem. A computer linked pharmacology system, such as that described from Birmingham, seems an ideal preventive and learning tool. This system sends warnings when incompatible or otherwise dangerous drugs are prescribed, and the introduction of such a system nationwide could prevent hundreds, indeed thousands, of errors. Errors in diagnosis could be minimised by better training and wiser use of protocols and diagnosis algorithms.

Errors are problems what will not go away. A pilot study by the Royal College of Physicians into deaths after admission for medical emergencies suggests that some error occurred in as many as one in five cases, although not necessarily leading to an adverse event (unpublished). These data should be interpreted cautiously but do suggest that actual recorded adverse events are the tip of the iceberg. Analogies are often drawn with airline pilots. These are over interpreted in that an aeroplane should behave predictably on all occasions, whereas every patient is different and the same disease can present on myriad ways. Nevertheless, we can learn from the airlines, as David Johnson suggests. They spend a much higher proportion of revenue on training and they report all incidents, with “blame” being minimised. This is a habit which we should adopt, but it required a much more sympathetic approach from management than has pertained in the past.

There are no magic bullets. It was emphasised at the countenance that training alone will not solve the problem. There must be a healthy supportive culture in the work environment for improvement for to occur. No quick results can be expected. A leader should have the courage to admit his mistakes. This will encourage others.

We need to put in place a national system for recording adverse events. This is an enormous undertaking and could be introduced initially in high risk areas but in the end it should be a matter of course in every medical setting, public and private. Only then will we really learn and improve our practice to the ultimate benefit of the public.

Doctors, however experienced and eminent can never sit back and rest on their laurels. They must constantly be reading and sharing their experiences with their colleagues. As Lord Lister is reported to have said:

*Please note that the author has expended considerable professional effort in the production of this article and full reference is available in the original article.