Understanding medical error, Publisher: Karachi Bioethics Group. pp 53.

Movie version – To err is human, Producer: Centre of Biomedical Ethics and Culture, SIUT, Pakistan. 12 minutes. Available from: https://vimeo.com/153865932

This handbook on Understanding medical error by the Karachi Bioethics Group addresses an important but taboo topic in healthcare. It is a slim manual of 53 pages intended to shed light on identifying, managing and minimising medical error. The dictum oft quoted in medicine ‘primum non nocere’ is just the beginning. The complexity and demands of the current healthcare system make this dictum grossly inadequate to describe what is expected of a physician today. The booklet is especially relevant in the current atmosphere of distrust which surrounds the medical profession.

The book starts with the statement “Errors must be accepted as evidence of system flaws, not character flaws”. With this statement, the battle lines are drawn. The patient and the doctor are NOT adversaries. The initial chapter strives to shed more light on the subject. The authors describe in detail, with apt examples, the difference between “medical error”, “medical negligence”, and “malpractice”. Negligence is the failure to meet a standard of care whereas medical error is a system error due to the human factor. They describe the nuance in the meaning of the words “adverse event”, “near miss”, and “complication”. For example, an adverse event is the harm caused to a patient due to medical care rather than an underlying disease. Complication is an adverse event caused by a pre-existing factor outside a doctor’s control. The book explains how missing the difference between these words can lead to a lot of avoidable mistrust between the doctor and the patient.

In November 2000, a 3-year-old girl died in a hospital in London when she was administered pure nitrous oxide instead of oxygen from an anaesthetic machine during an emergency resuscitation. Learning from that system error, a practice of mandatory minimum oxygen is maintained in a gas mixture in modern anaesthetic work stations.

The strength of the book is that the authors maintain an objective and neutral point of view throughout. First and foremost, they describe in simple terms why the field of medicine is prone to errors. Then, they look at the doctor’s point of view and explore the reasons why doctors remain reluctant to report medical errors. They look at the patient’s point of view to see how it benefits them to have medical errors reported.

The book is relevant to medical practitioners and patients, in that it raises the issue of medical errors. It provides a platform for an open discussion on the reporting medical errors between healthcare workers and patients. The suggestions offered in the book, though few in number, are practical and applicable in any healthcare setting. The tools that the authors offer as a way to minimise errors, like the use of checklists, digitalisation of data, departmental audits, mortality conferences etc, are indispensable.

A short 12-minute movie To err is human, accompanies this booklet and gives further examples of common medical errors. It depicts a case scenario in a hospital where a senior surgeon gets reprimanded by the hospital administration. A patient she operated on has had a swab left behind in his abdomen leading to a post-operative infection. The doctor defends herself by saying that the operation was gruelling and the entire team had worked hard for the patient. The administrator reminds her that if protocol was followed, such a thing would not have happened. The doctor pulls up another example of a medical error in the hospital which the administration has not noted. She explains that the wrong medication was administered to a patient but as it did not cause any problem to the patient, it went unnoticed. The administrator reacts saying that he will fire the people involved. The doctor concludes that due to this kind of response, many errors never get reported. The movie is thought-provoking as the scenario described could happen anywhere. Despite the flow of the movie being jerky, the message comes through in the end. Part of a series of bioethics educational videos presented by the Center of Biomedical Ethics and Culture, Pakistan, the movie is available from: https://vimeo.com/153865932

Dr Atul Gawande, in his book Complications, notes that although medical errors are thought to be confined to a subset of bad doctors, in fact they follow a uniform bell-shaped curve. Honest reporting of errors remains a crucial first step in preventing them from occurring in the future.