[Re: https://www.hifa.org/dgroups-rss/spotlight-patient-safety-and-ncds-22-mi... ]
Dear Christine,
Thank you for your kind message. It was hard to write the original message. My intention was to give an example of a patient safety incident from my own experience, and thereby encourage other HIFA members to share their experience. We haven't yet heard any other personal experiences yet, whether from a health worker or patient/family perspective. I am convinced that such sharing can help us to understand the impact of unsafe care and its causes.
You say "I could share much greater physician errors that I’ve witnessed in my career". It would be interesting to hear more about these, from you and from others. Please email to: hifa@hifaforums.org
I am sure we could could identify hundreds of examples from the literature but communication is more powerful and educational when it is personal.
"That counselling you should have been offered is not too late..." Yes, I am sure it would have been very helpful at the time. More so, it would have been helpful to have a hospital review of the case, which I believe would have made it clear to me that the primary factors were systems-related rather than 'my fault'. Although I submitted my own account I did not see an overall account of the case. I was left to 'get on with it'. As Charles Vincent said in his response, 'This was indeed the understanding of error and harm that was common at that time when I was working on errors in medicine as a researcher in an emergency department. We now understand that the great majority of events that harm patients have a much more complex set of causes and contributory factors.'
https://www.hifa.org/dgroups-rss/spotlight-patient-safety-and-ncds-11-mi...
Preparing and sending my account to HIFA has turned out to be cathartic and healing for me. I reviewed my own statement from 1986 and came to realise more fully that I was indeed 'set up to fail' by the systems I was working in. Looking back objectively, I provided reasonable care (and so did my registrar). The factors that contributed to the death were primarily health system factors.
Over 40 years I had felt some responsibility to have 'missed' the diagnosis of epiglottitis at the first assessment. Only while preparing my account did I read that epiglottitis is notoriously difficult to diagnose and that 80% of cases are not diagnosed at first assessment. It's curious that I did not learn this at the time - that would have been very helpful. In effect, now I realise that I did what any other junior doctor in paediatrics would have done.
Out of curiosity, I asked Copilot 'how many patient safety incidents occur in a doctor's career?' and it answered 'a typical doctor will be involved in hundreds to thousands of patient-safety incidents over a full career. Only a minority of these are due primarily to an error by the doctor. Most incidents arise from system failures, workload, communication breakdowns, equipment problems, or team-level issues, not from a single clinician’s mistake.'
If other HIFA members are willing to share an experience of unsafe care, we can all learn from this, as I hope you have from my example. Email: hifa@hifaforums.org
All the above begs a further question: How best to support a health worker who HAS made a serious error, perhaps resulting in disability or death. And how to prevent such errors.
Best wishes, Neil
HIFA profile: Neil Pakenham-Walsh is coordinator of HIFA (Healthcare Information For All), a global health community that brings all stakeholders together around the shared goal of universal access to reliable healthcare information. HIFA has 20,000 members in 180 countries, interacting in four languages and representing all parts of the global evidence ecosystem. HIFA is administered by Global Healthcare Information Network, a UK-based nonprofit in official relations with the World Health Organization. Email: neil@hifa.org