Medical misadventure: the secret sickness

Like everyone, doctors make mistakes. In the first of a three-part review, health reporter MARTIN JOHNSTON looks at what the profession calls 'adverse events.'

Dr Robin Youngson once nearly killed a patient by oxygen deprivation.

He turned the wrong knob on the anaesthetic machine, delivering pure nitrous oxide instead of oxygen. Used with oxygen, nitrous oxide is a light anaesthetic. Without oxygen, it is a lethal poison.

"I was a minute away from killing a patient but I realised my error and corrected it. The patient wasn't harmed," he says of the incident 12 years ago.

It was an easy mistake to make and not an uncommon way for patients to die, the Auckland anaesthetist recalls.

But the risk has now been removed by improved anaesthetic machines and a device to monitor patients' oxygen levels continuously.

Dr Youngson is surprisingly candid about the incident, given the widespread perception that doctors close ranks against claims of error.

The incident illustrates the safety risks he is trying to highlight to persuade hospitals, health workers and policymakers to fix faulty systems.

Patients have been left reeling by revelations about cervical smear under-reporting, incorrect prostate testing, slip-ups in cleaning surgical equipment, syringe reuse, and a gynaecologist allowed to continue under supervision (but since suspended) after repeated findings of negligence and mishap.

Some cases, which suggest deeper problems, have shuttled between medical authorities for years. Action to protect the public and get to the bottom of the problems, such as in the Gisborne cervical cancer inquiry, only followed media scrutiny.

In line with overseas rates, New Zealand health officials estimate that 10 to 17 per cent of patients suffer an "adverse event" (unintended injury) in our health system, which includes public and private hospitals, general practitioners, nurses, dentists and other health workers. Half are preventable errors. The rest are known complications, such as surgery that fails.

No one has produced any New Zealand research, although Professor Peter Davis, of Christchurch Medical School, is expected to publish results of the first study soon.

A 1995 study in the Australian Medical Journal found that 16.6 per cent of hospital patients in Australia suffered an adverse event and of them, almost 5 per cent died.

The South Auckland Health chief executive, David Clarke, says about half the "adverse events" in Auckland occur in hospitals and half in the wider health sector.

He calculates that 5 per cent of patients at Middlemore, Auckland and North Shore Hospitals suffer such events.

Of the preventable half, a tenth are thought to cause death - that is at least 0.25 per cent of all admissions. If the same applies nationally, that is 1000 deaths a year.

But others, drawing on overseas work, calculate that our annual death rate from preventable "adverse events" could be over 3000 people.

Medical error rates have caused alarm overseas. United States authorities aim to halve errors in five years with safety recommendations including mandatory, confidential reporting to a federal agency.

Authorities here want to set up something similar, plus a "credentialling" system, run by senior doctors, in which the competence of medical practitioners in public hospitals is regularly reviewed.

A joint Ministry of Health-Health Funding Authority paper on error-reporting notes that, as in Britain and the United States, our health sector is behind other potentially risky industries like aviation and engineering in improving safety.

The question of confidentiality in the reporting system, as suggested in America, will be controversial. It is already disturbing patient advocates, but without anonymity, health workers may feel exposed and not support the scheme.

Anonymity is preferred by Dr Bob Boyd, the ministry official chairing the working party developing the system here.

The risk of patients filing formal complaints constantly worries many doctors. But Dr Youngson says owning up to errors with patients and trying to help them greatly reduces the chance of legal action.

Accident Compensation is bracing for an increase in the number of medical misadventure claims it handles from 1100 in the past financial year to 1400 this year, after several years of reductions. The figure seesaws from year to year and is driven up by high-profile medical failures, such as those of retired pathologist Dr Michael Bottrill, which triggered the Gisborne inquiry.

Misadventure divides into medical errors (including negligence) and mishaps (rare but severe complications). Last year ACC found medical error in 84 claims and mishap in 479, a total of 563.

Dr Youngson has taken a risk with his frankness over his own and his profession's fallibility.

It has been costly, in an environment where, he believes, doctors are trained as "solo stars" with unrealistic expectations that they will not make errors.

When at conferences he challenges them to admit mistakes and address their causes, some accuse him of destroying confidence in public hospitals.

"We all make errors," Dr Youngson says, asking who has never let a laundry tub overflow or left car lights on, flattening the battery.

He says hospitals are beset by "bad information systems" - mostly huge piles of paper. A patient's notes can be up to 30cm thick - thousands of pages - "and crucial information could be hidden in the middle of it."

Drug prescriptions generally still rely on doctors' often bad handwriting, but Dr Youngson points out that it is a whole system fraught with potential error. It relies on the doctor's memory for information including the dosage, allergic reactions, and interactions with other medicines.

"The nurse might give the wrong tablet or injection because she has hundreds to choose from in her trolley and she gets distracted. Or she might get the right drug but give it to the wrong patient because she gets distracted, or there are two patients with the same name in one ward."

Dr Youngson says computerised drug dispensers starting to be used overseas eliminate almost all those errors. The machines, which can access the patient's records, can even bubble-wrap the prescribed dose.

These systems cost "many millions."

But one study showed adverse events cost United States hospitals the size of Auckland Hospital around $5 million a year in further treatment and longer stays.

Four per cent of United States health spending went on treating the victims of adverse events in 1998. In New Zealand that would be $280 million a year.

So even on economic grounds there is a strong case for investing in safety systems.

Middlemore's David Clarke is keen to spend more taxpayer money on patient safety. His organisation spends $3 million to $4 million a year on safety, but it comes from savings on other services. There is no specific Government budget for safety and he believes one should be created.

His wishes look unlikely to be fulfilled. Health Minister Annette King's diversionary answer, when asked if such a budget will be created: "Funding agreements with District Health Boards will include a requirement to provide services to agreed standards."

But she points to various Government moves to improve safety, including legislation to tighten disciplinary systems.

Dr Youngson says his commitment to honesty about mistakes has already paid off with patients and in improved systems. After explaining to one patient that he had anaesthetised the wrong arm, a nurse later brought him a message: "The patient said, 'Don't worry about it."'

But he never told the oxygen-deprived patient, because there was no damage done.

*What the doctor ordered: Gentamicin, Morphine, Augmentin. Sevredol