off record
Shaukat Ali Jawaid


Reducing morbidity
and mortality through
“Never Events”


Avoiding and overcoming Medical Errors as well as “Never Events” could significantly reduce the morbidity and mortality in healthcare facilities. What it calls for is better administration, upholding professional ethics and seriousness on the part of all healthcare professionals.

“Never Events” were first introduced in Hospitals which meant that these events should be prevented or avoided. These include  Falls and Trauma, Surgical Site Infections, Vascular-Catheter associated infections, Pressure ulcers, administration of incompatible blood, Air embolism, Leaving foreign objects unintentionally after surgery, Surgeries performed on the wrong side, Surgeries performed on wrong patients besides wrong surgeries performed. Better healthcare can be ensured with few interventions and more surgery does not mean better healthcare all the time.

Similarly Medical Errors are reported to be responsible for thousands of deaths even in the developed world which has one of the best healthcare set up. Despite effective monitoring and accountability, medical errors does take place there. What may be the true picture in developing resource constrained countries including Pakistan where healthcare professionals are overburdened and have to work under lot of stress and strain with meager facilities, is not difficult to imagine. However, despite all that, if the hospital administration is efficient and careful, looks after the genuine needs of its staff, provides comfortable, secure working environment, the chances of Medical Errors can also be minimized if not eliminated altogether. While minor medical errors are not so costly and near misses could be tolerated, it is the fatal medical errors which needs to be taken seriously.  Proper clinical audit, regular morbidity and mortality meetings by the healthcare facilities and documentation should be encouraged. It must be remembered that Medical Errors are most often system failures rather than failure of the individuals. Hence, it is the system which needs to be looked into and changed.  In United Kingdom now 90 days mortality of all surgeons is available on the website as all surgeons have to put their results in the Registry. It has also helped in improving patient care to a great extent.

Unfortunately in Pakistan we still lack proper audit, monitoring and accountability of healthcare professionals but it does not mean that the situation will not change in the days to come. Hence, it is advisable that the professional specialty organizations should initiate and undertake monitoring and accountability of their members before some outside agency come in and starts doing that.

Tail Piece: There is no Medicine like Hope. No incentive so great and no Tonic so powerful as an expectation for something better tomorrow - Orison Swett Marden.

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