The recent tragic story of a three-year-old’s death after receiving dental care under local anesthesia in Bengaluru is heart-breaking. I am a surgeon who treats patients and performs procedures everyday. I am also a father of a three-year-old and an eight-month-old. The aftermath of the incident would have been unpleasant for the doctor and the family. I am sure this incident sent shivers down every patient that walked into a healthcare facility.
I have received and delivered health care in India and in the United States. Where is it safer? What does quality mean? What does informed consent mean? How do we move to a system that can minimise preventable errors? The goal is not to speak of this specific incident but really to educate the community – patients, families and maybe, health care professionals.
Years back, the airline industry developed a system to make flying as safe as possible. A critical concept was to understand and accept that the system needs redundancy to pick up preventable errors. A well-designed health care delivery system can make care safer and decrease the incidence of preventable medical errors. The Institute of Medicine reports that medical errors and healthcare-associated conditions lead to some 200,000 preventable deaths per year in the Unites States. I assume this number is larger in countries that do not have a robust quality system.
A nice point to start our conversation on what will be a series of short pieces on medical safety, errors, doctor-patient interactions and improving the quality of care we deliver would be to understand what the airline industry went through. Captain Chesley ‘Sully’ Sullenberger III – the captain who successfully landed US Airways Flight 1549 in the Hudson River in New York City has a fantastic interview on the topic http://med.standford.edu/121/.
Capt. Sully says 50 years ago investigations were against the pilots and they ended there. It was easiest, he says, to blame the dead pilot. In plain language – moving from blaming a person, to identifying the root cause and improving the system. “To Err is Human” the 1999 report put out by the Institute of Medicine, acknowledges human beings, however good they may be, are not perfect. However, with appropriate structure, processes and transparency the system can drastically reduce the errors.
Fifty years back, the captain of the plane ruled the cockpit. The airline industry has moved to a system where the captain is the leader and builder of a team. Change requires the captain of a health care team to listen and welcome the comments of any person in his or her team. The team in my opinion includes the patient, the doctor, the nurse, the pharmacist, the cleaner, the list goes on. The prima donna attitude has no place any more in quality health care. The aviation industry is a perfect system for health care to learn from.
As a surgeon, I want to deliver safe and quality healthcare to every patient I treat everyday – I think most doctors do, I hope all will one day. But, I am human. Some days I am tired, some days I may not have slept and some days I may be sick. The system, when well-designed, can protect the patient from human error. Maybe there is a need to create a system that does not allow unethical practices as well.
As a father I want my children to be safe when they walk in to a hospital. I understand and acknowledge that not all complications are preventable but I want to ensure that no harm is done to my children. I hope the next few pieces will raise questions, awareness and help healthcare professionals and patients to build a safe healthcare environment.
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