Medical error

Not in my name

 

A recent coroner’s report caught my attention (highlighted by HSJ’s Shaun Lintern via Twitter). A patient died from a ruptured aortic aneurysm, and during the investigation it was discovered that it had been seen on a CT scan four years earlier. However, the patient never came to hear of it, the GP was not informed, and no follow-up was arranged. The coroner now requires the Trust, through a letter to the Secretary of State for Health, to review its arrangements for flagging up ‘non- cancerous but significant and potentially life-threatening findings’ on scans.

The aspect that worried me was that the consultant, who had read the report and was intending to tell the patient in clinic 5 days later, never saw him. He was seen by a trainee, and the trainee either did not see the scan result or did not understand its significance. This made me think about clinical decisions being made in consultants’ names, but without consultants being aware of them. Does this really happen? Yes.

Consultants lead teams. In some clinics, 30 or 40, even 50 patients will be seen in a consultant’s name, but because the consultant is only able to see perhaps a third of those personally, the rest will be seen by trainees. Those trainees will have some specialist knowledge, but they may be three or four years out of med school. As trainees, they are supervised, but the level of supervision will vary.

During my training, I never saw a clinic where trainees discussed all of their patients with consultants. Rather, consultants relied on trainees to use their judgment and ask questions about challenging cases when they felt it was necessary. Then, as now, many patients were seen, investigated (and perhaps discharged) without the consultant having been directly involved in the decision. This is more common in bigger hospitals, where there are more trainees and larger clinics. It may sound alarming, but just as junior doctors see patients in the emergency department or on the wards, and make important decisions day after day, so they do in clinic too. (In fact, the terms ‘junior’ and ‘trainee’ sit uncomfortably with experienced professionals in their thirties.) Nevertheless, if a trainee misses the point entirely, or overlooks a subtle sign or important result, there is always the possibility that a dangerous conditions could slip through the net.

On the wards, every action and decision is made in a consultant’s name. I remember explaining to relatives, and on one occasion a coroner, why certain clinical decisions were taken by another – perhaps at night when I was not even in the building – but ‘in my name’. When pressed by both whether I thought those decisions were ‘right’, I had to pause. If it had been me on the ward at that time, I might have interpreted the information differently. I might have prescribed a different drug, or referred to another specialist sooner, but… it wasn’t me. It was a trainee, and they did what they thought was best. It wasn’t wrong, but it wasn’t necessarily, in retrospect, as right as it could have been. If there were errors in judgement, short of outright negligence or something amounting to an incident that requires reporting and the duty of candour, it will be dealt with through their educational supervisor. It would seem wrong to allow the full weight of responsibility to lie on the trainee’s shoulders. After all, I have to remember – a few years ago, that trainee could have been me.

So what is the consultant’s responsibility here? Are they truly responsible for the patient’s outcome, even though certain important decisions are not in their control.

Well someone has to be responsible. Consultants stay in one hospital for a whole career (usually), while trainees move on. In the case of the missed aneurysm there was a delay of four years before the error was noted. The trainee who may or may not have seen the result, or who failed to chase up the results of the scan, would have moved on. They are out of the frame. It was the consultant who had to explain what happened to the coroner. In that case, ‘the system’ took the blame (the way in which x-rays were reported and flagged). This is often the case, and in a blame-free culture that encourages reporting of error, it often has to be the case.

The system is often inefficient. The system may have intrinsic gaps which are unsafe. As doctors, we complain about the system all the time, but perhaps this is where our responsibility truly lies. To be open to the possibility that the system we are working is imperfect, and to accept of our role in improving it. That is why consultants must also be continual improvers of quality. It is not enough to moan. If weak areas are identified, we must engage in strengthening them. If we find gaps, we must close them. We must complain, escalate, and help to fix. That is the quality that should be scrutinized, rather than the (superhuman) ability to detect and personally manage every patient who passes through our service.

 

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Interactive Ward Ethics 2: Dangerous

This is the second interactive post, and the scenario places our long suffering but excellent medical registrar, Nina Charan, in a no-win situation. She observes a colleague, another registrar, making a complete mess of a delicate medical procedure, and has to decide how to deal with it. Should she ignore it, manage it herself, give him time to improve, or escalate her concerns immediately? What may look obvious, from a patient safety point of view, becomes more challenging when you think about the psychology and emotional risks.

The choices you make for Nina will lead her into various stressful consequences, although some will result in a satisfactory outcome.

I recommend using the back arrow on your browser to move back if you want to take another route. There is a route map in the Summing Up section.

Click here to enter ‘Dangerous’.

Patterns and pride: diary of a medical anecdote

…There is, it seems to us,
At best, only a limited value
In the knowledge derived from experience.
The knowledge imposes a pattern, and falsifies,
For the pattern is new in every moment
And every moment is a new and shocking
Valuation of all we have been.

T.S. Eliot, East Coker (Four Quartets)

Day 1
It was a good day today. There are not many occasions when you recognise the clues, feel bold enough to make a diagnosis, and see admiration in the eyes of your colleagues – some of whom didn’t even know who you were.
The patient came in with fever, he was referred as just another pneumonia or a urinary infection, but I noticed that one of his blood results was unusually high. The eosinophils. This led me to ask about his travel history, because these cells often go up when there are parasites in the system. And indeed he had travelled, a fact that no one else had thought to ask. I looked up the country in which he had spent time, and worked out what sort of parasites could be involved. But I knew which one already. The symptoms seemed to fit what he was describing, to the letter. Fever, abdominal pain, some weight loss, and especially breathing difficulties that he had developed just before coming to hospital. It all fit.

strongyloides
So I looked up the treatment, called the pharmacist to make sure we had it in stock, and prescribed it. By the end of the day he was already feeling better. It made all the study seem worthwhile. But it was a special memory that served me so well today. I had seen a patient just like this one during my elective, in Africa. I even wrote about it in the report that we had to hand in, so it stuck in my brain. Strongyloides. I suppose, over a whole career, many such images and stories will find a place in my memory, to be retrieved at a later date. Nothing wasted, they all find a niche. A good day.

Day 2

I went straight into see him as soon as I arrived. He was grateful, and asked how long it would take him to get better. I said I would refer him to the tropical disease specialist, as they see more of this sort of thing. And of course I explained that we needed to confirm the diagnosis, even though I was pretty sure about it. I reviewed his blood tests, and saw this kidneys weren’t working so well. He must have got very dehydrated before he came in. His breathing had settled slightly, but he was still struggling. I didn’t want to come across as an expert, because I have only ever seen one other person with this. But he’s on the right track.

Day 3
I was disappointed today. His kidneys were worse, despite the fluids that I prescribed. My consultant didn’t have any new ideas, she was pretty happy to go along with my explanation. But she was keen to see confirmation of the diagnosis. The antibody tests will take days, they have to be done in London. She asked me whether it could be any other parasite, or any other type of infection full stop. Perhaps she doesn’t quite trust my impression. It made me think, and reflect. But I’ve seen the list of parasites, and none of the others that he might have acquired in Africa present like this. So I suggested that we push on with the current treatment. It worked last time, I explained.

Day 4
Weird. He was confused today. This parasite can affect the brain though. I spent 45 minutes on the phone trying to get through to a tropical disease expert, to see what they thought. They agreed, yes, Strongyloides can go into the brain. So I arranged a scan, and it’s happening after hours tonight. The anti-parasitic agent we’re giving him will kick in soon.

Day 5
I went to see him but he wasn’t there. I ran into another SHO in the corridor who had been on call overnight and he told me he’d been transferred to the intensive care unit. I almost ran. When I got there I found him unconscious, on a ventilator. He was surrounded by other doctors. There was a neurologist, examining his eyes. I asked what was going on. He had blown a pupil, I was told. It didn’t make sense. I saw a nurse returning from one of the computers. She was shaking your head. ‘What!’ shouted one of the other consultants, a rheumatologist. ‘They must have done it!’ he said. I faded into the background, but I continued to listen. What angered him was the fact that during the patient’s entire admission, no one had sent off a vasculitis screen. As soon as I heard that word, vasculitis, my heart dropped and the muscles in my legs grew week. I had to sit down behind the nurses’ station. I realised that I had made a huge mistake. For vasculitis is another main reason for eosinophils to be raised. I knew immediately what is the diagnosis was. Churg-Strauss syndrome. I had missed it completely.

Day 9
I met with my clinical supervisor today. I had asked for the meeting. I told her what happened. I could tell that she thought my mistake was a bit stupid. She asked me what my thought processes were on the day the patient came in. I explained the whole story, how it rung bells in my mind, how the words that he used, and the clinical examination findings, had taken me back to a vivid moment in my training. And I had questioned the data, and I had tested the hypothesis, and it all seemed to fit.

‘But what about the differential diagnosis?’ she asked

‘I… I…’

‘Did you develop one?’

‘I did, I think. I’m n…’

‘Did you write it down Emma, in the clerking? Did you test for anything else?’

‘I didn’t think I needed to. It was so clear.’

‘Well, to be fair, the patient saw a lot of other people, and more senior than you, before he got really ill. No one really challenged the diagnosis. There’s a lesson for all of us. But it shows you the power of a positive diagnosis. Especially one that appears to be supported with confidence. You’re a junior doctor, but you see how much weight people give the opinion of anybody who seems sure of themselves. Yes, diagnoses should be challenged by more senior doctors as they review patients, but it is not uncommon for them to defer to the opinion of the first doctor who really got their teeth into the case. And that was you. You made a plan, it made sense, the patient even got a little bit better at first. Sometimes, I think, there is really one chance to set things into motion in the right direction, and that’s on the first day of admission. It’s a big responsibility. Am I making you feel any better?’ She smiled. Then she asked, ‘What would you do differently next time?’

‘I won’t be so confident.’

‘That would be a shame, if you are right.’

‘Well if I really think I’m right, I will make my case confidently. But I will make sure there are caveats, and that other avenues aren’t closed off right at the beginning. Perhaps in this case, because he had raised eosinophils, he should’ve seen a rheumatologist anyway, even if I really thought he had an infection.’

‘I’ll tell you what I take away from this. The power of anecdote. In your mind there was a clear story, and narrative that you had seen played out before, one with a happy ending. You were sucked back into that memory. If you’re like me, your memory works best when it’s embedded in stories. But I guess that might be a disadvantage, if you can’t stand back and approached each case with pure objectivity. Attack each case with fresh eyes, but use the stories that you recollect to remind you of all the possibilities.’

‘I hear you.’

‘And one more thing. The Procrustean Bed.”

procrustes‘The what?’

‘His confusion. It challenged your hypothesis, it didn’t make sense, but you rationalised it, and made it fit your idea – a parasite in the brain. Procrustes chopped or stretched travellers who encountered him until they fit the size of his bed. You not only fell into the trap of anecdotal memory, but you tailored your interpretation of the data so as to support it…’

‘There is one more thing.’

‘Tell me.’

‘I was pleased with myself, on the first day. I elated, to make a difficult diagnosis.’

‘That may be the most valuable lesson of all. It’s seductive, the warmth that being right gives you. But don’t worry, you’ll experience enough reverses in your career to learn that pride is never to be entertained. I think you’ve learnt enough from this particular case, don’t you! How is he by the way?’

‘Getting there.’

– – –

Note: This case report from the CLEVELAND CLINIC JOURNAL OF MEDICINE explores the clinical scenario in more detail.

spokenunspokenPAPER

Intersection

intersectionfigure2

This is a brief tale of two patients who never met, but whose lives became briefly entwined with huge consequences.  Until the day that saw both became ill their life lines had not intersected before. Suddenly those lines veered from their usual course and dived across the city towards a bland, anonymous nexus…the hospital. They arrived within an hour of each other but were too preoccupied with their own symptoms and fears to become aware of one another in adjacent cubicles. Their relatives passed in the corridor, and may have stood in line together at the coffee machine. The patients, an elderly man and a thirty-five year old woman, were seen by different doctors. His angina settled with morphine, oxygen and nitrates; her asthma attack eased with nebulisers and infusions. She was transferred to the medical high dependency ward for monitoring, he to the coronary care unit. Their lives diverged once again as they were transported to different ends of the hospital.

At 2am his angina leapt back up for attention. The nurse looking after him turned up the nitrate infusion, but bleeped the doctor on call as the pain score rose from 7 to 9. The doctor responded and began to make his way to the ward. He knew that the ECG was essentially unchanged – the nurse had told him so, and he trusted her interpretation. She had seen a hundred times more ischaemic  ECGs in her career than he had. But he had a plan – intravenous beta blockers, to slow the heart and make the myocardium less hungry for oxygen.

As he turned the penultimate corner his bleep went off again. He spotted a phone hanging from the wall and called the number. It was HDU. A young woman with new onset asthma was deteriorating. Oxygen saturations were dropping, she was confused, peak flows were unrecordable…every red flag he could think of was being waved.

The coronary care nurse knew what needed to be done. Her patient’s pulse was 95 beats per minute, but a simple injection could bring it down to 65 and ease the pain. He was clutching his chest, pressing on the sternum as though to reach into the cavity and tear the source from his body. And now, on the cardiac monitor, she saw definite signs of ischaemia. Where was that doctor?

The doctor turned the final corner…and entered the high dependency unit. The asthma patient was close to collapse. He laid her down, began to assist her breathing with a bag and mask, and calmly ordered the nearest nurse to summon the entire medical emergency team.

On the cardiac ward the nurse had gone so far as to draw up the beta blocker in readiness. She was quite prepared to tell the doctor what to do if necessary. Then she would phone the on-call cardiologist herself to discuss emergency angioplasty. Nervous now, she walked from the bed space to the desk, in order to bleep him again. He had said he was on his way, and, though she couldn’t be sure, she thought she had heard his footsteps approach up the corridor five minutes ago. He must have got distracted.

‘Good call,’ said the anaesthetist on the emergency team, ‘…she needed intubating. I’m glad you didn’t hang about.’ The junior doctor felt good for what he done. He had recognised the red flags and had responded to them efficiently. As he left this scene of minor glory (he had qualified only 18 months ago after all) the crash bleep sounded. He and the rest of the crash team ran to coronary care, leaving behind only the anaesthetist who continued to ventilate the asthma patient.

They worked on the elderly angina patient for 25 minutes, but his heart could not be coaxed back into life. The many injuries it had accumulated before and since the bypass operation 18 years ago meant, for reasons we don’t fully understand, that once its lifelong habit of beating had been interrupted it would not be restarted.

His family were shocked, but not surprised, if that combination of reactions makes sense. They knew nothing of the junior doctor’s genuine intention to see their father, nor of the badly timed phone call that caused him to turn around and walk away from the coronary care unit. There is no way of knowing if his arrival would have made a difference…but it might have. So here we see how the life lines of two patients eventually crossed, the exact point of intersection being in that corridor, where the beige plastic phone hung on the wall, when the doctor on call decided to prioritise the needs of one before the needs of another.

A hospital represents a huge exchange in which hundreds and thousands of life lines touch each other every minute, altering in subtle ways the medical decisions, therapeutic actions and clinical outcomes of complete strangers. This sounds strange…and not a little wrong. A patient’s outcome should depend on several things, but not on the nature of their neighbour’s competing condition! On any given day the care a patient receives will be influenced not only by the vagaries of their own illness, the expertise of the doctor they encounter and the compassion of the staff they meet, but by numerous factors beyond the essential medical dynamic. The concentration and character of life lines running through the great nexus will also determine what happens. This fanciful representation may reveal a degree of caprice that we would rather not admit to, but we witness caprice every day, in nature and disease, in human response, in physiological or pharmacological idiosyncrasy. It is unavoidable. While we marshal these random factors into a logical, safe and personal management plan to the best of our ability, it does no harm to remind ourselves that the job of picking apart those life lines and prioritising their needs can never be an exact science.

 

[The cases are fictional]

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The eyes and the ears: why Adam blew the whistle

Previously I wrote a dialogue between two junior doctors. They discussed why Michael would not report, to some higher authority, the dangerous incompetence of a consultant. In this second dialogue, Adam explains to his friend why he phoned the GMC to report dangerous staffing levels. This dialogue seeks to illustrate why a doctor might feel compelled to act, rather than just watch, shake their head and move on.

This is imaginary, obviously. It is intended to describe the thoughts that a whistle blower might have.

Adam and his friend sit in a beer garden. Adam occasionally looks over his shoulder to check who has taken the adjacent table.

“Was it you?” asks Adam’s friend.

“What?”

“Who called the GMC.”

“What did you hear?”

“That someone blew the whistle on A and E.”

“What else did you hear?”

“That it was about staffing levels, lack of support…it was you wasn’t it?”

“Why do you think it was me?”

“Because you’ve been going on about it for ages.”

“That’s the point I guess. I wasn’t seeing any changes at all. I was out of ideas.”

“So did you actually complain first, officially…through proper channels?”

“I told the clinical lead that I thought we were too thin on the ground. Several times.”

“And what did she say?”

“That it ‘will get better’. That ‘when the deanery send us more juniors we’ll be fine’. Mañana, mañana.”

“Did you have examples, of poor staffing leading to bad outcomes?”

“How can you get that evidence? We’re working on the ground, struggling, we work our arses off to keep the ship afloat, some people die, most don’t, how do I know if any particular death is directly related to not enough staff? How do I know if our department has got more deaths or delayed diagnoses that average? I don’t have that overview.”

“So how can you justify blowing the whistle? You don’t know that the department was actually under-performing.”

“If you follow that line of reasoning, no-one would ever stand up and say anything, they would have no confidence in their own opinion. ‘I’m just a cog in a machine, I’m not driving the machine’. To justify NOT saying anything you have to have complete faith in the driver. Do I have faith in the driver? I don’t know, I don’t know the people who run the hospital . All I know is that sometimes it’s hell in that department and patients are falling off their chairs in the waiting room.”

“And despite not knowing, you made the call. Where did you develop that confidence in yourself?”

“It’s not confidence. It didn’t come easy. I waited for months and months before making that phone call. Nearly a year in fact. But nothing was changing.”

“It has now.”

“I know.”

“You should feel proud.”

“I don’t. I just feel sick when I walk through A and E. At least staff move through it so quickly the current set of juniors don’t recognize me as the troublemaker. The consultants do. But a few have told me that they are pleased I did it.”

“Weren’t they embarrassed?”

“No, I don’t think so. They thought the same as me. When someone actually does it…does something positive, everyone suddenly says ‘Yeah, I agree, it’s unacceptable…’. Like the emperor’s new clothes, everyone pretends it’s fine, they can manage, then someone pipes up and the truth becomes clear to all, undeniable. Weird psychology.”

“But why did it take your call? The Trust knew about the situation, the department was aware…not just from your comments…but it took the fear of a GMC investigation to do anything.”

“I honestly don’t know.”

“Has anyone from senior management spoken to you?”

“Yep.”

“And…?”

“It was all very reasonable, understanding, respectful in fact.”

“Fake?”

“Actually no. We got into a good discussion. He made me feel relaxed, and we went into it in some detail.”

“Such as?”

“The bigger picture. He allowed me to push him…to draw him out…to reveal HIS thoughts about whistleblowing. It wasn’t the greatest example of whisteblowing in history was it, really, more of an alert I think…so I don’t think he minded talking about it. So we got into the bigger picture. He encouraged me to think about scale, to think about the hospital as a unit, providing care to all of its patients and to the whole community. Elective and emergency. Babies, kids…not just the sort of patient I was seeing. Those in charge have to decide where to put the resources, where to place the staff…”

“So only they have the overview, and the knowledge…”

“Perhaps, but it went further. I said yeah, you have to make hard decisions, to ration basically, but you in turn are being rationed, by the government, who have demanded that you save x million this year as a share of the £20 billion of efficiency savings. He liked that.”

“He didn’t really agree to pass the buck onto the government did he?”

“Not as such. But perhaps he should have. I might have sympathised with him.”

“You can take the bigger picture further you know Adam.”

“How?”

“To society as a whole. Why does the government demand we save £20 billion?”

“Because the economy is screwed. Austerity.”

“Yes, that’s the environment we live in. But within that environment the government has decided to squeeze the health service because it has a duty to maintain other parts of the state at the same time. Defence, social security, prisons…so in their eyes, the bigger picture demands that Trusts feel the pain. That’s the price of austerity, of long term economic stability. We don’t have that overview, the really big overview.”

“You really believe that? No wonder you didn’t make that call. You’ve intellectualised it to death.”

“Perhaps.”

“I said I sympathized with the big picture, but ultimately it doesn’t cut it. Because it’s not our business to care about the bigger picture, don’t you see? Resources are be sent down according to the best judgements or intentions of our political masters, or moved around the Trust by our senior managers, but we must concern ourselves with what the effect of those decisions is at ground level.”

“Humour me a minute Adam, I’m not criticising you…but why whinge about those decisions? We live in the big picture. We are citizens in a democracy, we, as a society, voted for austerity and hardship. We ARE cogs. That’s the state we’re in, we should just do our best within it. ”

“It doesn’t matter. We, as doctors, work in a small world, the hospital…and we are there to make patients better. We are the ones with the eyes and the ears to tell the ones who move those resources around that their decisions are proving destructive. We are the ones who must tell them if minimum acceptable standards are not being maintained. Who else is going to spot that? If not us, who?”

“But doesn’t everyone think that their little domain is under resourced, straining to maintain minimum standards? We can’t have all of them ringing the GMC helpline.”

“I agree. And that’s why it took me a year. I challenged myself over and over again, told myself it was just me, just a bad run of shifts, that my seniors had recognised the problem and were dealing with it…but nothing happened! So I did it. I reassured myself that it was up to me to tell them that here, in this case, the balance wasn’t right.”

“Eyes and ears.”

“Yep. That’s what Francis said.”

“And mouths too.”

 

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The cusp: ethics of the learning curve

learningcurve

 

There is a moment in medical training when you think you are ready to go it alone. The difficulty is deciding when that moment has arrived. Independence, working without supervision, is a watershed moment.

Imagine this situation. A gastroenterology registrar who believes that she is ready to deal with bleeding ulcers receives a phone call. A patient is bleeding in the ER. She makes arrangements to bring the patient to the endoscopy unit. She decides not to call her consultant because he has said on a number of occasions that she is ready. He has ‘signed her off’. The patient now awaits her; she takes the endoscope and passes it into his mouth. She finds the ulcer quickly and knows what to do. But it is bleeding rapidly, and the views that she obtains are not very clear. She knows what to do. She washes the ulcer, tries to clean the blood away, but still it bleeds. She begins to feel nervous…even more nervous. She asks for a needle with which to inject adrenaline, hoping that this will slow the bleeding down. Then she might see enough to apply some definitive therapy, a clip or thermal coagulation.

She waits for the endoscopy nurse to get things ready, and watches the patient. The elderly man is sedated, but his pulse rate continues to climb despite the blood transfusion. The registrar knows that she would rather her supervisor was here. But then she reflects – this is what independence is about. Coming out of your comfort zone, absorbing the stress, dealing with the situation, making the decisions, …enlarging that zone… making yourself better so you can treat the next patient with even greater confidence and skill. But what if that process involves putting this frail man at risk? She readies herself for the next part of the procedure. She knows that if this goes well she will emerge from that room a better doctor.

The scenario can now go one of two ways…

A. She injects the adrenaline and as she had hoped it has a constricting effect on the blood vessels, causing the flow to slow down. Now when she washes the blood away it takes longer to ooze back, and she can see the culprit in the middle. A raw artery that has been eroded by acid. She chooses to use the heater probe and asks the nurse to make it ready. She passes it down the channel of the endoscope until she can see it emerge on the screen. With one hand she controls the wheels on the endoscope to optimise the position, and with the other she presses the heater probe onto the vessel. Then, with her right foot she presses a pedal on the floor and sends electricity into the probe, creating a tiny zone of intense heat until the vessel is ‘cooked’. Thinking that she has sealed artery she pulls the probe away. But the bleeding is even worse now. She must have torn the wall away. Quickly she calls for a clip and the nurse passes her the kit. The registrar pulls out the heater probe and quickly, calmly, replaces it with the clip delivery device. Soon she sees the metal jaws, grossly magnified, floating around the field of scarlet on the TV screen, and although the view is flooding with blood again she can still glimpse the artery. Before the window of opportunity has passed she pushes the clip onto the artery and asks the nurse to deploy. The clip closes down on the artery and stops the bleeding immediately. The field clears and she places two more clips above and below. The patient is stable.

“Well done,” says the nurse “that wasn’t easy. You could tackle anything now.”

B. She continues to wash away the blood, but the view is terrible. She injects adrenaline and it slows things down, improving the view. Now the time is right to use the heater probe. She places its tip on the ulcer, right on the vessel that is spurting blood, and presses the pedal. The heat dissipates into the pool of blood, and makes little difference. She knows that a clip is the next best thing, but she needs a better view. She readies the clip, and through the other channel of the endoscope she squirts more water. The view improves and when the time is right she deploys the clip. For a while she thinks that the job is done, she sighs in relief and smiles at the nurse, but 30 seconds later the bleeding erupts again and all views are lost. She takes out the camera, bleeps another member of staff to come and help look after the patient, and rings a surgeon. He arrives quickly, but argues that the patient is too frail to undergo an operation. The registrar argues back, saying that she can do no more within the scope. They debate the pros and cons of various other treatments, and in the end agree that surgery is the only hope. The patient is anaesthetised and in the operating theatre 40 minutes later. The ulcer is located and sealed. But he does badly after the operation, and develops a chest infection. He remains on a ventilator, and in the end, seven days later, dies.

The registrar describes all this to her consultant. From the description he can see no reason for her to blame herself.

“You did fine.” he says, “You knew when to give up, that’s half the skill.” He doubts that his presence would have made much of a difference. But the registrar knows that the patient’s greatest chance of survival would have been afforded if he had not had to have an operation, if the most experienced person had been there to treat the ulcer…if she had not proceeded on her own.

*

As a trainee approaches the top of a learning curve the moment comes when they have to decide if it is safe to go it alone – the cusp. The patient who comes into hospital on that day will have no idea that they represent a significant moment in the career of the doctor who is called to perform their procedure. They will have no idea where they lie on that learning curve, or that they might form a stepping stone to independence and immaturity. This would not matter if their risk of harm was no greater than that of any other patient having the procedure. But it is the result of this risk analysis that forms a perfect example of how we balance individual risks versus societal benefits in medicine.

The concept of the learning curve was introduced to many members of the public in a horribly vivid way during the Bristol Heart scandal. One of the paediatric heart surgeons involved said,

“I believe that the reality of the learning curve may be illustrated by the evolution of surgery for transposition of the Great Arteries in this country … in the late 80s and the very early 90s it was generally understood and accepted that when a unit introduced the Arterial Switch operation for neonates there would initially be a period of disappointing results.”

I am not concerned with such extreme examples here, but the essence pertains. In order to achieve complete expertise it is necessary to accept a degree of ‘trial and error’. Or is it?

*

A thorough enquiry into this subject was undertaken by a US paper, the Dallas News, following controversial reports coming out of Parkland Memorial Hospital, the primary teaching institution of University of Texas Southwestern Medical school. This hospital seemed to take a liberal attitude to the surgical training, crediting its juniors with autonomy to proceed with many operations unsupervised.

One faculty supervisor who quit in protest said the mainly poor, minority patients of Dallas County’s only public hospital had effectively become “clinical fodder.”

Apparently,

The head of UT Southwestern’s general surgery residency program once said it was “OK for residents to make mistakes” on patients “even if they could have been avoided with better faculty supervision,” according to notes taken by a faculty surgeon and later included in court records. Tim Doke, UT Southwestern’s spokesman, challenged the accuracy of that account. But Anderson has testified that some faculty believed “that’s how people learn,” though he said he disagreed with the philosophy.

In this case (and the newspaper report makes excellent reading, as does this graphic summarising mortality), one supervisor became uncomfortable, and complained after he was called into a gall bladder operation too later, after a irreversible damage had been done to the bile duct.

This controversy crystallises an ethical dilemma in medical training. As the journalists put it, “There’s good for the patient, and there’s a societal good. We can’t exist as a society without physicians learning on the ground.”

A questionnaire study published in the BMJ found that 86% of surgical trainees or young consultants had performed procedures for the first time without direct supervision. This appears to be the reality of medical education. Attempts have been made to resolve the dilemma, another BMJ paper seeking to lay out a framework based on respect for the individual, beneficence and non-maleficence. In their introduction Jagsi and Lehmann explain that…

The burdens of medical education are not currently distributed fairly. In one US study, students saw disproportionately high numbers of non-white patients and patients with Medicaid (public insurance for the indigent).Another study found that children of doctor parents were less likely to be seen by trainees than were other children.

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Immanuel Kant (image from Wikipedia)

However, the approach laid out in this paper does not really equip trainees with a practical method of making decisions on the spot. Another paper (Journal of Medical Ethics) approaches the problem by applying Immanuel Kant’s Second Formulation of the Categorical Imperative,

‘‘Act so that you use humanity, as much in your own person as in the person of every other, always at the same time as end and never merely as means”

In reality however,

This conflict arises because, at least presently, medical practitioners can only acquire certain skills and abilities by practising on live, human patients, and given the inevitability and ubiquity of learning curves, this learning requires some patients to be treated only as a means to this end….Accordingly, until a way is found to reconcile them, we conclude that the Kantian ideal is inconsistent with the reality of medical practice.

To resolve this conflict,

…supervisors might undertake to delegate only under conditions where they can be as sure as possible that the procedure would be done as well as they could do it themselves. If this assurance can truly be given by the supervising doctor, then the conflict is solved.’

 

This seems unrealistic. So are the patients who take their place on our learning curves nothing more than a means to an end? The paper begins with a quotation from Atul Gawande’s book Complications: a surgeon’s notes on an imperfect science

‘To fail to adopt new techniques would mean denying patients meaningful medical advances. Yet the perils of the learning curve are inescapable—no less in practice than in residency’

Le Morvan and Stock seek to challenge the perception that patients are guinae pigs in four ways;

1) Discontinuing unnecessary use of patients without consent – they suggest that we introduce a consent process where possible. The example of pelvic examinations by students on anaesthetised patients is one such example.

2) Continuing to develop medical simulation models

3) Enhancing supervision, but…”We are sceptical that such an approach, applied stringently, is practical for all procedures. It is hard to imagine—for example, that an experienced surgeon can honestly say that his trainee’s first liver biopsy will be performed just as well as he would perform it himself. Moving in this direction, toward a more conservative educational model, would, however, reduce the extent to which patients are used as means only.”

4) Changing expectations, or universalising the problem. If the involvement of trainees is taken into account when the statistical outcome from a procedure is calculated, patients waiting for that procedure are not actually being disadvantaged by having performed by a trainee. This argument does have a whiff of sophistry about it, but I have found myself using it before. As a patient and a parent I would want the hospital’s best qualified person to treat me or my children (although I am probably too polite to demand as much), but as a trainee I often muttered to myself, in response to a patient’s underwhelmed expression, “Look, either I do this procedure or it’s another five hour wait…what will it be?” As the authors conclude,

It does, however, offer a useful way of approximating this ideal in light of the constraints imposed by the reality of medical practice.

I don’t think there is a way of truly resolving the Kantian conflict unless our patients accept that it is not possible to always see the most qualified person in the institution. But the deal must be reciprocated by trainees – they must ensure that every single clinical interaction is approached not from the point of view of ‘polishing their resume’ (as the Dallas News article put it), but from the point of view of the patient. The trainee may well be on the cusp, there may be a theoretically increased risk, but if the skills are embedded, if the trainers have given their blessing, if they feel ready on that particular day or night…no more can be asked.

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The needle and the damage done: circumspection

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Scrolling through my timeline on Twitter the other day, I saw that a junior doctor had suffered a ‘blood splash’, presumably in the face. This is when a patient’s blood is sprayed or flicked into your mouth or eyes…carrying with it the risk of infection from a blood borne virus such as hepatitis C or HIV (medical staff are immunised to hepatitis B). It made me think back on a similar experience as a junior doctor…a needle stick injury from a patient infected with hepatitis C. I’ll describe what happened in a minute, not because I enjoy telling unpleasant personal stories, but because I think the impact that these ‘avoidable but let’s face it they’re going to happen now again’ accidents have on doctors and nurses should be understood and emphasised. When I looked into the subject I discovered that research had been published on the subject this year, the results of which I will go on to summarise. It seems that the psychological impact of these accidents can be very grave indeed.

*

As soon as I felt the deep sting of the needle as it entered my finger I knew what it meant – potential disaster. I was cutting a space between the ribs of a patient on intensive care, making room for the insertion of a large chest drain. The tissues were tough, and I had to tear at the fibres with my fingers deep under the skin. But the patient was not sedated, and she was feeling it despite the local anaesthetic injection I had administered beforehand. So I did something stupid. I kept one finger in the cut, so as not to lose the track I had struggled to form, and with my other hand I carefully inserted the anaesthetic needle alongside it. In this way I hoped to numb the deeper tissues. I jabbed my own fingertip – ouch…a shock, but not really painful. It was the knowledge that hepatitis C viruses in my patient’s blood could now be running up the veins of my arm and into my bloodstream that caused me to freeze in fear. I withdrew my finger, looked down at my hand, tore off the glove, and squeezed the fingertip until droplets came out. The nurse who had been helping me recognised what had happened, but had nothing to say. I walked over to a sink, washed the blood off, wrapped a waterproof dressing around the tiny wound and went back to the patient. She still needed a chest drain after all. Soon the job was done, and the rest of the nightshift passed without incident. But throughout the small hours I could think only of myself: were there any viruses in the needle? How many would it take to cause a permanent infection? Would I need anti-viral treatment, would it work, could I continue to be a doctor while receiving the famously toxic combination of interferon and ribavirin? Might it fail, would I develop cirrhosis, would I end up in this very hospital, waiting for a transplant? Oh God.

I was distracted by anxiety for weeks, not to a disabling degree…not so as anyone would notice. At six weeks I had a blood test to see if there were detectable levels of virus in me. A week later I attended the occupational health department to get the result. The nurse had not read a Hep C result before, it seemed to me. She looked quizzically at the small piece of paper in front of her, and tilted her head slightly.

‘Err…you have…err…Hepatitis C.’

I nearly fainted. I looked at the report closely, upside-down, and lunged forward,

‘Let me see that!’

I turned the report round and saw that she had misread a < for a >. I had < 50 virus particles per millilitreof blood, not > 50! I was negative! She accepted my interpretation, and was embarrassed. I left the room and walked back to my ward. My skin was cold and wet. I felt fifteen years older.

There were antibody tests at three and six months, and they were negative too. I was not infected. In fact, looking back, knowing more now about the absolute risks, and the cleaning action that plastic gloves perform as a needle passes through them, it was never very likely. But the experience changed me.

*

Professor Ben Green and Emily Griffiths (University of Chester) recently published a paper called ‘Psychiatric consequences of needle stick injury‘ in Occupational Medicine. They administered a depression questionnaire to 17 needle stick injury (NSI) recipients who had been badly affected enough to be referred to a psychiatric clinic. None were actually infected. They compared these results with 125 non-NSI recipients who had been referred for other forms of psychological trauma. The authors hypothesised that NSI caused shorter or less intense periods of psychological morbidity. Their findings included a description that I recognised immediately,

Four of the cases (24%) described an initial period of up to 2 days of acute anxiety, disbelief, tremor and profound sleeplessness consistent with an acute stress reaction.’

Within the (admittedly highly selected) group of 17,

‘Thirteen (76%)…had a diagnosis of adjustment disorder (AD). Four (24%) met the guidelines for post traumatic stress disorder according to ICD-10 diagnoses.’

Other observations included,

‘NSI patients with AD repeatedly said that although accident and emergency staff or occupational health staff had reassured them that the chances of seroconversion were small they focused on the fact that there was still a ‘possibility’ of seroconversion and thus did not feel reassured.

They concluded, among other things, that

‘psychiatric disorders in NSI patients were similar to other trauma-related psychiatric illness in severity, but while they last for 9 months on average, this was not as long as other psychiatric trauma patients. Psychiatric illness following NSIs had major impacts on work attendance, family relationships and sexual health.’

*

These individuals were at the worse end of the spectrum, and the conclusions reached in this paper do not apply to all NSI recipients. I wonder if there is a more subtle effect on those who do not end up being seen by a psychiatrist – a heightened, and more general, sense of self-preservation. My own experience brought it home to me that while my career would involve seeing hundreds or thousands of patients who might carry serious or incurable infections, there was only one of me. I resolved to do everything I could to protect myself…not to a paranoid degree, but by applying a greater sense of caution. So, instead of plunging into the next cardiac arrest situation without a care for the bodily fluids that were leaking onto the patient’s chest or bed, I held back until my gloves were safely on. I know that’s what you’re supposed to do anyway, but in real life people don’t. They rush to save the patient. When I saw a woman collapse during a night out in Soho I ran up to her, checked for a pulse, but did not contemplate performing mouth-to-mouth resuscitation without a mask. I felt selfish, but I could not face the prospect of waiting for more blood test results. (Mouth to mouth is out of fashion now anyway – and fortunately, she was breathing.) Beyond the arena of infection, I became less inclined to make sacrifices that might affect my health or put me at risk of making mistakes; swapping into crazy sequences of night and day shifts as a favour for colleagues, covering extra clinics when dog-tired…sensible behaviour, in no way abnormal, but a change. The damage done.

The Needle and the Damage Done is a song by Neil Young (Harvest, 1972)

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Hazard in context: the psychology of medical continuity

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Continuity of care in hospital is a hot topic. It is well recognised that reductions in the hours worked by junior doctors have resulted in a fracturing of the traditional team structure and more frequent handovers between staff as they come off shorter shifts. The Royal College of Physicians published a survey on the subject in February 2012, their press release saying,

‘…over a quarter (28%) of consultant physicians surveyed rate their hospital’s ability to deliver continuity of care as poor or very poor. In addition, over a quarter (27%) believe that their hospital is poor or very poor at delivering stable medical teams for patient care and education.’

Althought improved safety on the wards was a driver for change, a document published by the Royal College of Surgeons, ‘Do reduced doctors’ working hours create better safety for patients? – assessing the evidence’, challenged the assumption that working to the European Working Time Directive (48 rather than 56) led to greater alertness and fewer mistakes. The author Matthew Worral wrote,

‘There is a much greater evidence base to suggest the full-shift system being brought in increases patient harm through greater handovers and stratification of hospital staff. The potential for important information to be missed and inability to access senior expertise at key times are a greater problem for patients.’

Accompanying the move from long on-call periods to shifts has been a reconfiguration of the way patients are assigned to teams. In a soon to be published book ‘The Changing Role of Doctors’ (Radcliffe Health, May 2013), the main strength of the ‘old way’ is neatly described;

‘This firm structure, with the associated working pattern, meant there was a high level of understanding of one another’s strengths, weaknesses, training needs and personality. When this medical team was working at its best, all members of staff felt supported and there was a genuine sense of camaraderie and team spirit.’

and,

Continuity of patient care was of a very high level. Most patients were clerked in by a member of a firm (usually the most junior doctor) and then remained under the same team of doctors for the duration of the stay, regardless of where the available beds were.’

 

This contrasts with the new ‘ward based’ model, where,

‘…the junior doctor and consultant who first admit a patient will usually pass over the responsibility of care for the patient to another team as soon as the patient moves to an inpatient ward.’

 

The ward based model has significant strengths, not the least of which is that patients are directed to teams with expertise in their particular disease, rather than remaining with the ‘random’ team who happened to be on-call on the day they were admitted. Another strength is that work intensity remains constant, rather than fluctuating with the ebb and flow of admissions either side of an on-call day. A major downside is that whenever the patient moves within the hospital (into a side room because of infective diarrheoa, for example), her or she becomes the responsibility of another team. That team will have to review all that has gone before, check the results, get up to speed, and carry on delivering appropriate care seamlessly. The process of developing a full understanding of the patient’s needs and goals must be repeated. Rapport must be rebuilt. Subtleties may be lost. Errors can be made.

What is at the heart of these errors? System failures, ‘dropped batons’, poor communication…all are likely contributors. Professor Roy Pounder, contemplating the effects of reduced working hours, highlighted these factors in advance of the EWTD changes:

“Seeing a patient once or twice before handing over to the next doctor, who then does the same after a short period, means it is difficult to detect a subtle deterioration in a patient’s condition.”

But I wonder if there is a deeper issue, related to the way doctors understand their patients. The psychology of discontinuity. This needs to be adressed from the point of view of both patients and doctors.

Patient experience: anchorage

A 2002 BMJ paper, ‘Continuity of hospital care: beyond the question of personal contact’ offered some good insights into patient experience, using the following quotes;

“They keep asking the same questions…”

“My file was not present and new doctors were not informed of my situation”

“You always get different orders from new doctors”

“Too many doctors! A second opinion is OK, but the sixth and seventh are quite frustrating…”

These are the more obvious symptoms of discontinuity, but they do not describe fully the sense of vulnerability and frustration that I have sometimes detected. When I see a patient in the emergency department or acute admissions ward, a common question is,

“Are you going to be my doctor now?”

or,

“Will you be coming back to see me again? Will I see you tomorrow?”

I interpret such questions as an appeal for permanence or anchorage in the huge, complex system into which they have been delivered. Patients, it seems to me, are desperate to make a connection that can be relied on. If I know that the patient will come to my ward, I can answer ‘Yes, I’ll be along to see you tomorrow…’ and there may be a visible relaxation in their anxious expression. But if not, I have no choice but to explain, ‘No, it won’t be me who sees you from now on…but one of the other teams, lung specialists…’ Sometimes, if I have spent a good deal of time speaking with them, digging down in important medical or social details, I will add, ’But we will make sure they know all about you…about everything we have discussed…’ If it is a crucial fact I will make a point of telling the new team, but more often than not such hand-over of information will occur on paper, in the notes. This requires a clear handwritten entry, a transparent narrative. It is not uncommon for me to see what has been written by the junior doctor accompanying me only to realise that they have not interpreted the patient’s words in the same way I have. The emphasis is not quite right. So I re-write it, and leave the ward hoping and expecting that whoever receives that patient will see my note and make sense of it. This is an attempt to maintain the chain of continuity.

I wonder if the psychological distress that derives from uncertainty, not knowing if someone in the machine ‘owns’ you, if someone is personally invested in your wellbeing, may be sufficient to undo the benefit of technically correct, well timed medical interventions.

Fast track empathy

How do lack of continuity and the diminished feeling of ownership that follows, influence doctors in a way that jeopardises safety? It may hinge on empathy.

Serious illness requires the application of powerful medical interventions. These bring with them the potential for hazard. Recent debate about ‘zero harm’ culture has crystallised the notion that medicine and its tools can do as much harm as good. To avoid harm staff must be vigilant; they need to keep an eye on the details, spot irregularities, check the blood tests, double check the drug charts, maintain the ‘housekeeping’ (as it is sometimes called), and anticipate complications. These duties should be automatic, but they are done better if the doctor knows the full story. If they have gained a full appreciation of the patient and their background they will understand better the true impact of those potential harms. Risks and harms can appear abstract, but when they are imagined in the context of the whole person they become tangible, transforming from theoretical ‘adverse events’ to personal tragedies. A better understanding of those risks may motivate doctors to work harder in ensuring that each job is done properly. Otherwise they will not be letting down, ‘…the lady in bed 25, acute kidney injury…’, but ‘Mrs Jones…she was hoping to get out in time to attend her grand-daughter’s wedding this weekend…’ Continuity encourages personalisation, personalisation permits the exercise of empathy, and empathy gives our actions relevance.

The challenge for doctors working to shift patterns and caring for patients who arrive to their ward areas on a daily basis, is to learn the practise of empathy in compressed timeframes. This requires active listening, generous emotional investment…energy. But to ensure that connections between patients and doctors are made within the restrictions of the modern hospital environment this has to happen. Otherwise patients will flow through wards without knowing if anyone really ‘owned’ them, or who that person was. And doctors will float from patient to patient without understanding quite how much trust was being put in them.

Memory failure after medical error: the building blocks of experience

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There is a contradiction in medicine that has always interested me – the need to form a complete psycho-social picture of each individual patient (aiding empathy) versus the need to depersonalise, categorise and store their medical story (thus adding to experience). When things go wrong, this tension results in a paradoxical lack of humanity.

Example: a junior doctor, two years qualified, makes a mistake. She writes the wrong antibiotic up on a Friday afternoon, having failed to check the result of cultures that were taken three days before. The bacteria causing the infection is not sensitive to the antibiotic that she prescribes. The patient deteriorates. The doctor recognises and regrets her error, watches the patient and his family, learns all that there is to know about his life and background. He dies two weeks later (his death the result of mutiple diseases, not just her action). She is devastated. For days and weeks she reflects on her mistake. A vivid image of the family keeps entering her mind, as do their words, when they asked how a simple urine infection could make someone this ill. Moreover she checks the computer assiduously before prescribing antibotics from then on.

Twelve years later she is asked to deliver an induction lecture to new doctors. She emphasises how important it is that they check each result for themselves, take nothing for granted…watch the details. She is a very careful doctor, always was really, except for that one slip which happened early on. She drives home…and casts her mind back to the moment she learned that her patient had grown worse over the weekend, due, in part, to her brief incompetence. She finds that she cannot remember his name. She cannot form a picture of his face in her mind’s eye. The family…how many were there? The man has gone…only the error, and the lesson that grew out that error, remains. The individual has been subsumed by history, by a thousand other patients with a thousand different problems.

We cannot be expected to remember every patient, of course. But those who made the greatest impressions on us might, you would think, linger on in our memories. Indeed they do, but mainly in the form of salient facts – the features and factors that made them special, be they medical, situational, or personal. Their memory survives as a construct that exists only in relation to the effect it had on you, the doctor, rather than the self-contained, individual and tragic story that the patient’s demise truly signified in their world…a world that you, as their doctor, were never really a party to.

It is a subtle and rather esoteric observation, I admit it, but for me it feeds into a larger question. How do doctors ‘process’ the memories of patients who once presented a great medical or personal challenge?

A mature doctor will have been buffeted and battered by numerous ‘bad outcomes’. That cold phrase describes unexpected injury, suffering or death of patients related to decisions or treatments ministered by us, their doctors. Those outcomes may have been inevitable, but the fact that they occured after we saw them and gave advice forms a link in our mind. Was it something I did? Should I have made a different decision? Was I wrong? And if I was wrong, what will I do differently next time? A lesson is learnt, and each little shock, each piece of bad news, adds to the pattern of experience that forms the value of a good doctor. We carry those lessons around with us, making sure that next time we encounter a similar situation we do not make the same mistake. We get better, and feel more confident. The price – a series of personal tragedies that become smaller and smaller in our memory as time passes. All but the most harrowing (or perhaps those that resulted in sharp criticism or proessional censure) lose their emotional edge. We recall the events in abstract – ‘I did this, this happened, he died, I felt awful…oh yes, I don’t recommend it, don’t ever do that…’ – but we are no longer visibly damaged. In fact we are wiser and stronger, and at some level perhaps we are grateful for having been through it.

My point is that the lifelong process of learning that is a medical career requires us to find a way to live through these setbacks and make something positive out of them. To do this doctors must strip those memories of the very qualities that made them so powerful in the first place…the patients’ suffering and the impact this had on those around them. The lesson learnt is usually one of process, data interpretation, practical technique or communication…whatever it is it is something to do with the doctor. It is the doctor who is the constant, whereas the patient, even though their specific needs and problems formed the basis of the risk, is one of many who will cross that doctor’s path.

So is all this a problem? It is if we become too good at the process of assimilation and are tempted to put each mistake ‘down to experience’ too soon. It is if we do not dwell sufficiently on the impact of mistakes that, from a medical point of view, were purely ‘technical’. It is if we immediately compartmentalise those errors, surrounding (or hiding) them in hastily erected walls of rationalisation, forensic examination and (instinctive) defensiveness, thereby underplaying their social significance. I wonder if such post-hoc failures of imagination and empathy that can lead to a lack of candour. When errors are immediately assessed in relation to the system that caused them rather than the social unit, the family, that was most directly affected by them, we are in effect turning away from the pain and settling our gaze on our own concerns. That has to happen of course, if weaknesses in the system are to be adressed, but the timing and the emphasis have to be right.

Personally, as a doctor who has been blown off course as frequently as any other, I think depersonalisation and abstraction are vital. They are not particularly warm or human traits, but they are understandable. The process of learning from experience must be the same for doctors as it is for any other professional, and the same need to filter, discard and retain the ‘essence’ of each incident applies. The difference, for doctors, is that the extraneous matter is often deep emotion and human pain.

A ‘Never Event’ and the chain of the blame

This is an example of worst case scenario thinking. It is an entirely fictional case. I have used the same approach that I use in my medical fiction, working out how, within the boundaries of plausibility afforded by standard clinical processes and environments, a particular error might occur. Perhaps this accident happened somewhere, sometime…I don’t know.

This exercise in imagination is intended to show how difficult it is determine where blame lies. Few medical mistakes, in my experience, occur because one person made one mistake. There is often a ‘series of unfortunate events’, each one of which could, perhaps should, have been recognised and reversed before the next occurred. As I read about the ‘duty of candour’ in the Francis report on Mid-Staffs, and read about Jeremy Hunt’s response to it on behalf of the government, I reflected that each time a patient is harmed it will become necessary for hospital Trusts to make a judgement as to whether the incident requires a patient or family to be contacted (whether or not they have complained). It is clear now that there will be no legal compunction for individual healthcare professionals to admit to and communicate these errors, but organisations as a whole (embodied by ‘the board’) will have to recognise and act on that duty. It is not clear to me how this will work. Organisations are collections of individuals, and for the truth about avoidable harms to rise to the top those involved on the shop floor will have to be honest and forthcoming.

I wondered how individuals would respond in a ‘harm’ situation. I tried to imagined a scenario that should never happen, but did. Never Events are medical mistakes that the NHS Litigation Authority (NHSLA) have deemed avoidable and, to be blunt, indefensible. They are, ‘serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented.’ Never Events are reported annualy, and spikes in their frequency tend to be picked up by the press (as in Derriford, Plymouth in March 2013).

One Never Event is when liquid food is poured down a nasogastric feeding tube (NGT) that has been accidentally inserted into a lung. If food is dripped into such a misplaced tube the patient will literally begin to drown, and the consequences of this range from becoming transiently short of oxygen, to developing pneumonia, requiring mechanical ventilation or dying. Hospitals have protocols that are designed to ensure that this never happens, and the NHSLA has published algorithms to minimise the risk.

Here then is a reconstruction of how this Never Event might happen; as you read it, ask yourself who is to blame and how it might be communicated to the family.

 -/-

The date was 2rd February 2013 (a Saturday).

Mr Mohammad Ghazi was 78 years old, and had been admitted one week previously with a stroke which affected his ability to swallow. He was fed via a NGT, but on two previous occasions he had accidentally dislodged the tube.

Dr Martin Simpson didn’t know Mr Ghazi. He was asked to get involved at 5.30pm on the Saturday in question. The nurse in charge of the ward, Susan, called him to report that Mr Ghazi had pulled out his latest NG tube in the morning, and that she had inserted another at 3pm. However she could not get a reliable pH (gastric acidity) reading from the aspirate, which she attributed to him having residual feed in the stomach and the fact he was on high dose acid supressants. Without the acidity test she could not confirm that the tube was actually in the stomach, ans protocol dictated that a chest x-xray (CXR) was required. Martin agreed to arrange the CXR and promised to look at it before he finished his shift at 9pm. He asked Susan to bleep him when the x-ray had been done; he was going to be busy clerking new patients in A&E, as the registrar had requested that he help the admitting team during the traditional early evening rush. Martin sent an electronic x-ray request through and forgot about it. Someone would let him know when the x-ray was ready.

At 8.30 pm Susan walked onto the ward having popped out to pick up a drug from pharmacy for another patient. She held the door open for the porter who was bringing Mr Ghazi back from the x-ray department. She helped the porter wheel Mr Ghazi’s bed into the empty bay and, noting the time, went to bleep Martin. He answered promptly, logged on to the x-ray programme on a computer in A&E, scanned along the list of Mr Ghazi’s x-rays, clicked onto the one dated 3/2/2013 and saw that the tube position was perfect. The tip of the tube lay well below the diaphragm, it crossed the edge of the main airway, it was definitely in the stomach. He called the ward, Susan answered, and Martin confirmed that he was happy for her to commence the feed that night. Martin left at 9.30pm. Susan left at 10pm, leaving it to the next shift to turn the feed on.

At 11pm the ward sister on the night shift, Mary, answered the phone. It was the x-ray department, ringing to see if Mr Ghazi was available to come for his x-ray. Mary answered that he had already had it. No, said the radiographer, the request hadn’t been checked off. ‘Why was in he taken down to the department earlier then?’ asked Mary. The radiographer checked the system – oh yes, that had been for an ultrasound which had been booked a couple of days ago; the on-call radiologist had decided to do it that evening in order to clear the backlog. He hadn’t yet had the x-ray for the new NG tube.

Mary ran to the bedside. Liquid food was being dripped into the tube. Mr Ghazi was breathing badly. She stopped the feed immediately and called the medical team. The night doctor came to the ward and logged onto the x-ray programme. The x-ray that Martin had looked at was the wrong one – the right date, but the wrong time, taken in the very early hours of the same day to check the previous NG tube, the one that had been removed.

Mr Ghazi developed pneumonia, deteriorated and died a week later.

Investigation – assumptions and facts

The investigation showed that Martin had indeed looked at the wrong x-ray, and that the right x-ray had never been done. Susan was mistaken in telling Martin that the x-ray had been done – when she saw Mr Ghazi returning to the ward with the porter she had assumed, erroneously, that he had just had his x-ray. That assumption went unchallenged, and when Martin saw that an x-ray had been performed on the relevent date he assumed this was the new one. He did not check the time.

When the x-ray was eventually performed it showed that the new NG tube was in the right lung, and the lung was already turning white, filling with liquid feed.

Testimonies

Susan: I saw him being wheeled in. It was natural to assume he was coming back from his chest x-ray. I didn’t even know he was booked for an ultrasound. He had come to our ward the day before, it must have been booked when he was on the other ward. The timing fitted. Do I think what happened is my fault? No, actually. It wasn’t me who checked the x-ray…

Martin: I’d never met him. I didn’t know him, didn’t know he’d had an NG tube down just the day before, that it had been x-rayed overnight, at 2 in the morning! Susan…and I’m not blaming her…told me that he had come back from his x-ray. I saw on the computer that there was an x-ray taken on the day in question, it looked fine. Why didn’t I check the time? I can make excuses…I was rushing, but aren’t we all, all the time. I was clerking, when actually I was supposed to be on ward cover…but if I’d been doing that I would have been just a busy probably. You know, I can’t see how this could have been avoided. Not unless there was some way of linking the x-ray to the specific NG tube insertion. How could you do that?

Susan: His son came in, sat with him as he died. We didn’t send him to intensive care, he would never have survived on a ventilator. I explained how food had got into his lung, and he didn’t asl me how, or why… he didn’t assume a mistake had been made. And it wasn’t the right time to go into all the details then and there. He had to have some time to grieve…I think that’s reasonable. We didn’t hide anything.

Mary: I felt awful. I set up the feed pump. As soon as I turned it on the feed began to drip into his lung. I did that, I can’t get way from that. But should I, personally, have checked the tube was correctly sited? I don’t think so. I’m not trained to look at x-rays. Martin, the doctor, told me it was fine. I can’t do more than that…can I?

Martin: Because he wasn’t actually my patient I didn’t find out until the following Wednesday. The registrar on the stroke team came to find me, and let me know. She told me there was bound to be a complaint. I asked her straight away if the family had been told. I volunteered to tell them…but she said it would wait, and that their team would deal with it. But she did advise me to write everything down, all the details, in case I ended up giving evidence to the coroner. I went home and typed up a narrative… I still have it.

The clinical director: The simplest, harshest analysis is that Martin was negligent in not confirming that the x-ray he saw related to the new NG tube. If he had taken note of the time on the screen he would have realised immediately. But I’m sympathetic to his explanation. There was duplication. Two x-rays requested in a short period of time, less than 24 hours. Perhaps, just as we highlight and take special precautions if there are two patients with the same surname on a ward, we should highlight if two tests are arranged for the same patient…to ensure the right one is looked at. This terrible event has exposed a weakness in the system. I have never heard this happen before, anywhere. So it’s hard to say to the family, yes, we made a terrible mistake and did badly by your husband and father…we did, of course, but I cannot see where we could have done better on the night in question. The mistake was there waiting to be made, all the time. It could have been anyone who made it. We now need to look at ways of making sure it never happens again.

The Board (a representative): We were all agreed, we needed to tell the family. By the time we discussed it the initial investigations had been completed, and it became clear that the family had no idea that a mistake had been made. That made it more difficult than if they had been told straight away. It came as a complete and utter surprise to them, to the son anyway…he was the main contact. But even then there was no anger. It won’t always be like that obviously…but this family were philosophical, and took the view, very reasonably, that medical interventions come with inherent risks. We do not necessarily take that view – feeding through a tube should not be risky. That’s why it’s a ‘never event’. It is avoidable.

The family (his son): The Trust were candid with us. They called me, invited me in for an interview, and the consultant explained what had happened. Although I had never heard of Never Events, I realised once they admitted to us that it was food in the lung that killed him that this should never have happened. It’s basic. But I read their investigation, and I can’t see who or what to blame. The poor guy who saw the wrong x-ray, his is probably the greatest responsibility. But if I blame anyone I blame the Trust…did it go over how crucial it is to double check the time, did it train its junior doctors for that situation? Perhaps they should train nurses to read these x-rays, I don’t know. You might think that’s an over reaction, but this was supposed to be a ‘never’ event…and it happened. By definition therefore, inadequate preparations had been made. They hadn’t thought it through…not until my father died.

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