Mishaps in healthcare

Now I can write since I have created an experimental page.
Quoting from the Westmead Hospital Anaesthesia Blog, the complications of epidural anaesthetics given to dampen the pain of childbirth are either short lived and mild or extremely rare. The chance of becoming significantly disabled as the result of an epidural going wrong is approximately 1 in a quarter million births. Direct quote:
"The Key findings are

"Persistent neurological injury" seems to be the extent of the problem for the young migrant from China, who is now trapped in bed, unable to care for he perfectly healthy baby boy she gave birth to in 2010.

Frightening and devastating error during a birth at Sydney's famous St George Hospital.

At first I thought that a syringe had been mis-labeled and mistakenly given as an epidural. But no! The procedures I understood were followed by Australian anaesthetists from working with their database of procedures for several years, was that syringes were labeled with either the name of the drug and/or a special colour code indicating drug type. In the St George case, an antiquated tradition of placing both antiseptic (for disinfecting the injection site before injection) and anaesthetic injectable liquid into identical steel bowls on the prepared tray for the clinician was used! I have no idea of the details of the case, but it seems as though someone or several people have made errors completely out of line with anything you might expect.

Sure, poor Grace may be the one person in a quarter million who got the awfully disabling error perpetrated on her, but to her and her family this is still one case too many. Apparently the hospital is doing a lot in compensation, but the details again are hazy and the living arrangements for different members of the family are not ideal. It would be a wonderful gesture for the local community to step in and try to integrate them into the normal sorts of activities that young families might expect around there, so they don't become more isolated by their bizarre situation. Anyone out there listening?

As I've been working on dosing errors for my dissertation, this article stood out at the extreme end of tings that could go wrong after a seemingly harmless and common procedure. I know that individual epidurals are NOT easy, but the public expects them to be trouble free because they are suggested as routine. I have never heard of anyone except a nurse refusing to have an epidural on the grounds that they didn't want the side effects. I suspect that the public thinks an epidural is safer than having blood taken for pathology test.

We'd also probably have less errors if medical personnel didn't assume they were perfectly competent and actually confirmed everything they did with someone before proceeding. They've recently started surgeons on using checklists when performing surgery in Australia, which reassures me no end and anaesthetists have been using checklists and algorithms to regulate their performance for many years already. The result is an extremely low error rate compared with surgeons and well-placed confidence by the general public.

However, after just one mistake in 250 000 births, many will become wary of the epidural. Publicity like that is never good for the public, but how can we keep the medical profession accountable if the public never hears?

No comments:

Post a Comment