Wednesday, October 04, 2006

99.9% success is not good enough!


Horrifying as it may seem there are a number of cases every year in the NHS where patients have operations on the wrong part of their body.

The latest report says that 40 patients had this misfortune last year and while the Department of Health may tell us these are not high numbers, considering the millions of successful operations that take place, it is a significant increase on previous years.

Most of all it is tragic for the patients involved and it just unacceptable however we try to defend it.

What this reminds us is that any system - however carefully developed and checked - depends on human beings and as a consequence there will always be errors.

It is just not acceptable that patients suffer in this way and we have to do something about it.

5 comments:

David Wike said...

Honda had, and presumably still has, a philosophy that there was no such thing as a one-off problem. If it had happened once, then it could happen again and therefore warranted investigation. This rigorous approach may go some way to explain the reliability of their cars.

I wonder if the NHS takes the same approach to try to eliminate mistakes? However, although I agree with the sentiments, perhaps we need to keep a sense of perspective. If the figure was as low as 40, I would have thought that it was a pretty good performance given the millions treated. It also depends what is classified as treating the wrong part of the body. As you know Trevor, I do have an insight into the workings of the NHS. I understand that it is not unheard of for patients to be confused or apparently change their minds about what part of the body is causing the problem. Not surprisingly this can give the hospital staff a dilemma.

So your 40 cases could be relatively minor, for example the wrong wrist X-rayed or the wrong knee given a pain relief injection. I’m not saying that we shouldn’t worry; indeed an application of Honda philosophy would be good. But I wonder whether there are more important issues that need addressing, such as basic cleanliness and hygiene in hospitals?

Trevor Gay said...

Good points David and yes of course we need to keep things into perspective with this.

You are correct – a total of 40 cases is small when seen against the millions of successful procedures but try explaining that to the patients who, according to the report:

*Had the wrong leg amputated – 5 patients
*Had the wrong disc removed – 8 patients
*Had the wrong testicle removed – at least 1 patient
*Had an unnecessary hysterectomy – at least 1 patient
*Had the wrong set of lungs transplanted – 1 patient
*Had a circumcision after Doctors visited the wrong home – 1 patient

Yes it is well known for patients to be confused and yes in the grand scale of things some of the 40 recorded incidents may well be referred to as ‘minor’ but I suspect any patient who has been a victim of medical ‘mistakes’ might be forever affected emotionally.

I am however a realist and understand ‘nervousness’ about aiming for 100% but surely healthcare is the one exception. As patients we ‘hand over’ our bodies and we then surrender to the healthcare professionals who I accept have an awesome responsibility and I have every sympathy with them. I would not want that responsibility.

If we can expect 100% in car production then we must aim for 100% in healthcare.

Good to have differing views about this and I fully accept when I say we must aim for perfection that may not be achievable but as the saying goes – ‘if we aim low we will always hit the target.’

dicconzane said...

I agree with the theory. And that our health is of much greater importance than cars. However the reality is people pay for cars and car companies make the profits to do this. Health services do not. Nowhere in the world has yet found a way to make the health service fair, accessable to all and still make sure it has the money to get things 100% right. Suggestions I'm sure would be welcome.

Diccon

Trevor Gay said...

Diccon – Welcome to Simplicity Blog - Thanks for your comments and your request for suggestions.

One way of trying to achieve 100% and 'get it right first time' is to put more trust in the staff doing the work and allow them, in a supportive environment, to be in charge of the quality standards. Let teams be given autonomy within broad guidelines and minimum standards to develop their own methods rather than having arbitrary standards imposed by managers who are working too far away from the ‘coal face.’

I fully accept what you say about cars and profits and although the profit element is not necessarily a motivating factor in healthcare, what we do have is the huge majority of staff working in the NHS motivated to improve standards of patient care. What managers need to do is capitalise on that enthusiasm and not de-motivate staff and teams who know the answers. The best way to do that is to give them the tools to achieve higher standards.

kamagra said...

Wow that's dangerous because the disease it's reaching another countries so fast, so it's time to close frontiers.