The third biggest killer
There is a worldwide cultural problem which is afflicting the delivery of healthcare. The result is that, for the UK, it has been estimated that there are some 200 avoidable deaths in our hospitals every week. In addition there are the numerous episodes of harm that result. At least twice a week there are events under the banner of healthcare which ought never to take place. Wrong side, wrong site and even wrong patient surgery have been recorded. Incorrect judgement calls, inaccurate diagnoses, aberrant decision making and errors resulting from inadequate knowledge, miscommunication and lack of basic care. To err is human for sure. However the pattern of failure, often engendered by systems which have not adopted the necessary cultural change leads to the inability to prevent the preventable. Why this appears to be considered as inevitable in healthcare is both perverse and curious.
Dr Lucian Leape, at one time a pioneering paediatric surgeon in the USA developed a second career as a health analyst and became one of the leading figures in the patient safety movement. He began to highlight the major issues relating to error in medicine back in the mid 1990s. He observed “One of the most frustrating aspects of patient safety is the apparent inability of health care systems to learn from their mistakes. Tragic errors recur in new places over and over again. The solution to this problem is to investigate our errors and share lessons learned through a reporting system.”
Only now are we beginning to develop and use opportunities to properly investigate areas of concern in clinical practice and, importantly, find ways of sharing the lessons to be learned. There are many ways to do this – through managed clinical networks where systems with less good results can be flagged and appropriate enquiry established. The use of structured mortality and morbidity review presents an additional opportunity, still to become widespread in many specialties. A system highlighting best practice and a national framework to encourage this kind of learning is due for launch very soon. Already a Scottish guide to the operation of a national mortality and morbidity system has been published. Colleagues in aviation have long used checklists as a structure to maximise passenger safety and similar approaches have been demonstrated to be effective in the provision of safer surgical care. The checklists however have no inherent value unless they are properly used, by trained and dedicated teams, working in a culture which proactively seeks the safest possible system of care. It has also been clearly demonstrated that when shortcuts are used, standards slip and outcomes suffer.
It is high time that western medicine became alert to the fact that if medical error was considered as a disease, it would represent the third biggest killer after cancer and heart disease. We do not need to wait for some remarkable breakthrough to deal with this. It can be fixed right now. Safety is everybody’s business.