“Understanding Medical Errors”

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Karachi Bioethics Group launches its new Booklet

“Understanding Medical Errors”

KARACHI:  Karachi Bioethics Group formally launched its Hand Book on “Understanding Medical Errors” at a meeting held at Patel Hospital on Friday September 11, 2015. Speaking at the occasion Prof. Farhat Moazam Chairperson of CEBEC at SIUT congratulated the members of the KBG which has been active for the last ten years which in itself was commendable. Referring to the IOM of United States, Prof. Farhat Moazam said that for the first time it was reported in 1999 that medical errors were the fifth leading cause of mortality in patients in USA. What is an error is still debatable.

We are all human beings and it is not unethical but how one handles these errors, gives rise to ethical issues. Medical errors are patient centered in healthcare set up. We need to recognize our duties, respect the dignity of patients and know how to treat the patients with respect. Do No Harm should always get preference. Let us improve our systems otherwise it will harm others who will continue to make the same mistakes. She also talked about Truth Telling and said we must disclose when we have made some mistakes. There exists a relationship of trust between the doctors and the patient. There has to be a system which is shared.  How hospital administration handles these medical errors is yet another issue. We live in a violent society and we have to make a difference between negligence and medical errors which is of course not easy but difficult.

Dr. Kausar Khan spoke about issues of Trust and shared system and highlighted the importance of mitigating the sufferings of the patients. We must give due respect to the patient. Medical science is complex and dynamic but it is not predictable all the time, she added.

Prof. Murad Musa in his speech commended KBG for this wonderful attempt. It is important that we must look at the reasons for medical errors and also look into the psychology of medical errors. He also referred to cognitive errors and felt that we first need to discuss the practice of ethical medicine. It is important and these medical errors have its effects on the physicians themselves which are not recognized.  There could be genuine errors leading to serious complications and the physicians suffer. It has its effects on healthcare professionals which are not discussed.

Speaking about surgeon’s perspective Dr. Husnain said that we the surgeons learn from our mistakes. We have to live with these mistakes. It is the surgeon who knows what has gone wrong. When they are operating on an elderly patient, he may or may not survive. There is lot of grey areas. Society wants perfection; they have unrealistic expectations and wish someone to be held accountable when something goes wrong. In the teaching hospitals when the residents are operating, something may go wrong. As a result of the mortality meetings, we have been able to tell the truth in some cases, he added. Dr. Asif commended the KBG wisdom but added that to change thought process is difficult. We must learn from our mistakes. In the past there were many grey areas which have now become white and this process will go on. Medical errors, he opined, should not be made the basis of punishment.

Ms Arifa an infection control nurse descried the nurse’s perspective. She was of the view that it is difficult to identify errors. She then gave details of a patient who had spinal surgery for low back pain in a public hospital, developed bed sores and was then shifted to a private hospital with fourth degree bed sores. Eventually he died due to lack of care by the physicians as the doctor did not come to see the patient despite repeated requests of the attendant. She opined that we need to develop some system in hospitals and we also need to do something to reduce the risk of medical errors in public hospitals.

Mr. Pir Mohammad discussed the administrative perspective and said that we move when an error has taken place. If it is a minor thing, we try to counsel the patient and dilute the situation but if it something serious, we immediately transfer the worker who had committed an error to some other place to reduce hostile attitude. Sometimes hostile attitude of the patient is difficult to handle but we try to reduce their financial burden if it works. We have a Medical Errors Committee in Patel Hospital and we have learnt how to handle such a situation.

Dr. Bushra Shirazi introduced the booklet .Medical errors, she stated,  could be due to  wrong medication, transfusion of wrong person,  story of left swab, operating on wrong side etc. Now medical errors  is the 8th leading cause of mortality in United States and 98,000 people die annually due to medical errors. Medical Errors can lead to adverse events, complications. Some of these medical errors are preventable and some are non-preventable. Then there are near misses. It is important that once these medial errors have happened, there should be no finger pointing. The language used by the media related to these medical errors in Pakistan was more hostile as compared to the media overseas. Incident reporting system does not exist in Pakistan and instead of reactionary behaviour we need to concentrate on problem solving. We need to be pre-emptive which does not exist. She also talked about difficulty in admitting medical errors and imperfection, financial, emotional and ethical issues which are some of the hindrances in finding a solution to medical errors.

Dr. Bushra Shirazi was of the view that medical errors must be accepted as evidence of system flaws and not character flaws as recommended by IOM. Reporting of medical errors should be made mandatory. We must work to raise standards of safety through oversight organizations. Safe systems for safe practices need to be inculcated in the organizations. We should also enhance knowledge about patient safety, promote, recognize and accept scientific developments. For compiling this handbook, the five member group consisted of Dr. Yasmin Wajahat, Bushra Shirazi, Dr. Nida, Naima Zameer and Tayyaba Batool. We had about a dozen meetings and then prepared the draft which was shared with all the members of the Karachi Bioethics Group before the handbook was finally published.  The booklet was then formally launched. Dr. Mazhar Nizam from Patel Hospital presented the vote of thanks. Copies of this 52-page booklet were also presented to the participants.