14 July 2008

Never events

Operating on the wrong side is pretty disastrous. Perhaps to those outside medicine it may be inconceivable that this could ever happen. It doesn’t surprise Dr Grumble. Actually it surprises him that these things do not happen more often.

Proper procedures can bring about improvements. Just occasionally Dr Grumble finds an inpatient who has escaped being labelled. It worries him. That’s a mistake waiting to happen. But we haven’t always labelled patients. And we haven’t always labelled newborn babies. Many years ago Dr Grumble’s father introduced this innovation in the maternity hospital where he worked. Now it’s universal. Mothers no longer go home with somebody else's baby. But it’s difficult to make innovative changes at the coal face. Consultants certainly no longer have the power to do something so radical.

The Chief Medical Officer likes to make comparisons with the airline industry with its strong focus on safety and check lists. Check lists are thought to be one way to try and avoid errors in operating theatres. Probably they will help. But it may be easier to write check lists relating to the operation of an aircraft than for the ever-changing goings-on in an operating theatre.

In praise of check lists one often reads of the surprising finding that introducing a check list for the insertion of CVP lines saved 1,500 lives in the first month. Dr Grumble was stunned by this. For such a result it must have been that doctors were simply not doing what they should have been doing to insert a CVP line. Otherwise how would a check list have helped? How could doctors be so sloppy? Has Dr Grumble ever inserted a CVP line under less than optimal circumstances? Yes. Quite often. He has often not had the equipment he needed. He has often not had the assistance he needed. He has often not had the time that he needed. And, in days gone by, he was often exhausted. Check lists and a requirement that they be followed could well help. It is not necessarily the individual that is at fault. It is often an unsupportive system. And in which part of the NHS were the doctors’ efforts on CVP lines so sloppy that a check list was able to transform the outocme? Actually in was not in the NHS at all. It was in the US. Even Americans apparently take short cuts with their lines. It may even be that errors are worse over there than in the NHS.

But there's an ironic twist to this. Those smart US doctors who found an innovative way to deal with the sloppiness of those inserting CVP lines were sloppy themselves. They are now in trouble over the ethics of their study. It's a funny world.

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