3 seminal landmarks in the history of human error

The scale of human error often goes unrecognised because the events typically occur under the radar, and the link between cause and consequence are often never identified, or admitted. The impact of human error is also often not evident because, unlike in other high-risk industries like aviation, the victims are struck down individually and not collectively. But this notwithstanding, there are many watershed healthcare catastrophes that have exposed the gravity of human error, and which have instigated inquiries that have advanced the cause of patient safety.  Let us have a look at three of these, each reflecting different dimensions of the problem.

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Queen’s Medical Centre chemotherapy scandal

One of the turning points in the understanding of human error occurred at Queen’s Medical Centre in Nottingham in 2001 when Wayne Jowett was admitted for intrathecal (spinal) chemotherapy for leukaemia. He was appropriately administered Cytosine into his spinal fluid, but disaster struck when he was inappropriately given Vincristine via the same route instead of intravenously – a fatal error. The case was so tragic that it was investigated by a Public Inquiry carried out by Brian Toft which found that several errors of omission and commission culminated in the unfortunate mistake. These errors included the ward not requesting his chemotherapy ahead of his admission, as was the usual practice, and Jowett himself attending his admission unscheduled and at short notice. There was also a break in the established protocol not to administer his two chemotherapy agents on the same day, a measure put in place specifically to prevent the outcome that ensued. Other contributory factors the Inquiry discovered were the practice of typing the drug labels for both drugs in the same font and using the same colour.  The Inquiry however identified,  as “the most dangerous physical aspect of all”, the observation that “a syringe containing Vincristine can also be connected to the spinal needle that delivers intrathecal drugs to patients”. The recommendations of the Inquiry, which have since helped to mitigate this potential error, included the redesign of syringesdouble checking before injections are administered, and a review of the wider systemic failings that enabled the error to occur.

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Bristol Royal Infirmary Child heart surgery scandal

This infamous milestone in the history of patient safety is a lesson in the range of ways by which patient safety can become systematically compromised,  and in how difficult and risky it is for whistleblowers to expose and remediate the status quo. The scandal centred around the complex open heart cardiac surgery services at the hospital between 1984 to 1995, the magnitude of which led to a Public Inquiry chaired by Ian Kennedy. The scandal was exposed by anaesthetist Stephen Bolsin who systematically documented evidence of poor operating room practices and the high mortality of the operations performed by the paediatric surgery team. His attempts to highlight his patient safety concerns were however thwarted by the hospital, and his work, rather than earn him praise, made him a pariah. The whole episode culminated in his having to relocate his practice out of the UK. The Inquiry discovered several patient safety hazards including poor leadership, ineffective team work, and denial, and it made almost 200 recommendations including the requirement, not existing then, for practicing physicians to keep their knowledge and skills up to date.

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The Mid-Staffordshire Hospital scandal

This scandal is symbolic of the importance of the involvement of patients and patient groups in patient safety because the events that occurred at Mid-Staffordshire Hospital between 2005 and 2008 may never have come to light without the concerns they raised. The scandal was investigated by a Public Inquiry chaired by Robert Francis which found an unacceptably poor standard of care, and an unusually high mortality rate during the period of concern. The Inquiry found that the mortality rate in the hospital had been high for several years but this was never investigated by the hospital administrators who, on the contrary,  reacted to the concerns raised with denial and obfuscation. The Inquiry found a litany of systematic problems including poor record keeping, absence of patient management protocols and guidelines,  poor staffing, absence of training and supervision, inadequate equipment, and poor communication. Amongst the many recommendations the Inquiry made, perhaps the most important was to “foster a common culture shared by all in the service of putting the patient first“.

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These examples illustrate the diverse ways in which patient safety can be compromised, sometimes so imperceptibly that it takes a crisis to highlight. We will next look at how safety may be compromised in other industries.

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