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When a man can no longer conceive of a different condition he cannot challenge the present order. Posted by Dr. Jane Doe.

Posted Oct 28 2008 11:51pm
The above is my misquoting of Orwell. It reminded me, when I read it, of working in the Irish health service, and why I came here. It reminded me also of the recent serious medical error in Our Lady’s Children’s Hospital in Crumlin, and the subsequent root cause analysis.

As I read the root cause analysis that had been carried out by the consultants and patient safety and complaints manager from Great Ormond St hospital in the UK, for almost every single systems error they listed as a contributory factor, I felt a shiver of familiar recognition. Although I have never worked in either Surgery (except as an intern) or Paediatrics, I have many times been confronted with similar incomprehensible, inefficient, error prone, unnecessarily labour intensive and ultimately potentially dangerous systems in the Irish hospital environment.
Despite the frontline staff being actually superior to and more well trained than many other developed countries’ medical and nursing staff (Irish doctors and nurses are usually highly sought after and respected in NZ, Oz, USA and Canada) the working environment they face every day and night and the systems they navigate are at least twenty years out of date, thousands to millions of euros underfunded, and those that decide upon these systems often completely out of touch with the reality of working and being a patient in them.

The above sentence was quite long. Possibly not grammatically correct. But you get the picture.

In the root cause analysis of the series of unfortunate events that led to the ultimate error, eight factors were identified as being particularly responsible. Going through these one by one:

1) Delays in filing hard copy x-ray reports in the medical records, and lack of reference to an electronic copy:

The leading children’s hospital in the country’s capital STILL DOESN’T HAVE PACS?!
(Picture Archiving and Communication System)
Of the four hospitals in which I have worked in Ireland, three did not have PACS, and of those three, two were tertiary centres.
For those of you who don’t know what PACS is, it is a computerized system for displaying and storing radiology imaging and reports. You type in the patient’s medical records number and ALL their previous imaging, Xrays, ultrasounds, CT scans, MRIs and the associated reports are there, instantly. You can compare two chest Xrays from different dates, side by side, if you like, to assess for any changes over time. You can do this anywhere in the whole hospital that there is a computer.

You do not run around like some sort of nut frantically searching through pile after heavy pile of hard copies, spending often an hour to find one or two films when you should be doing your ward work, which you then have to disturb the radiologist for to get a verbal report, which then makes them slower, which then makes all other reports happen more slowly, which causes waiting for results, which keeps people in hospital…..

You just click with your mouse, like you SHOULD be able to in the bloody noughties, and what you need to diagnose/treat/plan comes up. Reports are all instantly accessible and attached to the images so you can even teach yourself a little something sometimes.
Mind you, in most of the hospitals I worked in there weren’t enough computers to even bother having PACS in the hospital anyway. My current NZ hospital has on average four desk based computers per ward that are only for checking results, not counting the ward clerk’s one (I counted yesterday), and three mobile laptops on stands with wheels that you bring around with you on the ward round to check patient results with instead of forcing your sleep deprived intern to come up with a plausible haemoglobin level when asked. The acute medical assessment unit has two high speed computers in each 6 bed room.

The last hospital I worked in Ireland had ONE per ward that the ward clerk used pretty much all day, and you were supposed to check results off of it too. They were shabby old slow puters too. No PACS though, so I suppose it’s not like they had to be fast.

For the overtime they paid us running around fetching films, and searching for films, and getting verbal and/or paper reports for films, and the increased length of time with resultant costs that patients stayed in hospital waiting for results, and the delays which ensued which also have a detrimental financial outcome on the hospital, they probably could have paid for PACS for a year. They sure as hell coulda bought some more and some better computers.
EVERY hospital in Ireland, rural or no, should get PACS as a matter of urgency. It saves time. It saves money. It may save lives.

2) The hospital should give consideration to extending the system of pre-admitting patients into general surgery:

Why? It’s much easier to force the overworked intern/SHO who has to work a forty hour shift with no sleep to admit someone they don’t know from Adam after hours where both services and access to senior advice are pretty limited. Hey with a little intimidation you can probably coerce them to consent for stuff they don’t fully understand too. You can do this for time and half of whatever they’re paid, on the ward, whereas a dedicated pre-admission clinic is going to cost money. It may pay for itself in time, as eff-ups are infinitely more costly than just doing stuff right the first time, but this has not in my general experience been a concept that is embraced in the current hospital system.

Currently where I work now there is a dedicated pre-admission clinic for all surgical patients and a separate one for Cardiology. In the surgical pre-admission clinic each patient sees a nurse, who takes their bloods, does an ECG, and even takes a Group and Hold (gulp, shock, but….but….only a doctor can take those! Right? Don’t they spontaneously self destruct or become toxic and venomous if anyone other than a doctor takes them? NO? Come on….
Actually nurses are better at taking Group and Holds. They have been trained to check procedures systematically, and hence rarely, if EVER get these sorts of things wrong. They are the ones who remember to date the IV cannula so it doesn’t stay in for two weeks and give the patient raging phlebitis and/or sepsis from same. If there is any doctor reading this who has NEVER been called back because they did something wrong or filled something in, somewhere, incorrectly, on a Group and Hold, I will give you my car.

Anyway. I digress. After they get their bloods and ECG done, they see the consultant anaesthetist who examines them, looks at their ECG, and pronounces them fit for surgery. Then they see the house officer who takes their history and examines them. Any concerns are relayed to the registrar of the team the patient will be coming in under. Any consents for anything the house officer isn’t familiar with and doesn’t know the risks for is taken by either the senior registrar or often the consultant. The house officer charts their regular medications, checks for allergies and then charts some routine post-op analgesia and anti-emetics so there isn’t any wait if the patient needs these after theatre.

See how the NZ system is NOT error prone? At every step every effort is taken to minimize errors, and maximize the chances of a favourable outcome.

See how a random intern or SHO admitting someone during on-call hours with no help, no anaesthetics review available, no senior help, often no way of consenting legally, and minimal nursing input ( this is important! The more a nurse is involved in any aspect of your care, the less likely an error is. They are trained to check, to spot mistakes and nag the team to rectify them. Marginalising them from patient involvement like we do in Ireland is detrimental to patient care) is a system designed to fall down?

3) The hospital should implement a process for initiating formal consent in outpatients, when patients are seen by a clinician who is personally competent to do the procedure and review the imaging, which is more likely (under the present system) to be available at that point. The process should also include a clear standard for the follow-up discussions to be held by the more junior staff who will admit the patient, from any specialty, and describe the circumstances in which the SpR on-call should be contacted, rather than deferring discussions until the following morning where there are significant time pressures. The hospital should consider stipulating that patients who are being admitted for major cases the night before must be re-consented by someone who is competent to perform the procedure and review the imaging:

I think I’ve discussed point three above. We need organised, dedicated, pre-admission clinics.

4) The hospital should introduce a correct site surgery policy, to establish best practice at all the relevant points in the patient's journey, from outpatient review to the point of making the incision in theatre. This policy should take account of recommendations 1 and 3 above. The review team acknowledge that patients are generally admitted to the ward by surgeons who are not considered competent to review imaging. If review of imaging is required in order to safely complete consent and site marking procedures, the hospital should consider stipulating that a more senior surgeon is called to the ward. If this is not achievable then the hospital should ensure that all of the other stages in the site marking procedure are robust enough to counter the risk of an inexperienced surgeon marking the incorrect side - or failing to mark the side - when the patient is admitted:

I agree. Again. Could be addressed with dedicated pre-admission clinics and a site marking policy. And consent should not be taken by people who don’t know what the procedure entails or what the risks involved are. That isn’t consent. Again-pre-admission clinics!

5) The hospital should introduce formal diary monitoring of junior surgical hours in accordance with the requirements of the European Working Time Directive, and in liaison with the appropriate external agencies ensure that the results are factored into ongoing workforce planning:

As long as they don’t do what they do in the UK, which is force the juniors to lie on their timesheets so that the hospital appears compliant, and then not pay them for the overtime that they did actually do. As long as they don’t do that. Hmmmmmm. They wouldn’t do that though. Would they???

Working 110 hour weeks with continuous sleep deprived spells of 35-55 hours at a stretch to me does not spell dedication, or generosity, or being exceptional, or even being hardworking. It spells inefficiency, abysmal workforce planning, reliance on out of date labour intensive systems, an inability to speak up, and the potential for danger. Some disagree with me. They are entitled. Many old schoolers think it’s a disgrace that the interns and 1st year SHOs in the countries who have brought in working hours reform now aren’t the first on to assess patients in the emergency department and the like. They bemoan how it will be the downfall of training, that no-one will be well trained now because they didn’t get this acute exposure early on etc etc.

I think that it’s fantastic. And I’ll tell you why. In the Irish system, with house officers of varying levels of experience and occasionally even interns, being the first to see patients, clinical errors are more likely to occur. I’ve seen and heard of errors that occurred because the SHO or intern had no experience of what they were dealing with, had no experience either in ED or on the wards of the condition they were treating, and the patient appeared to be pretty stable (but wasn’t) and they simply did not have the experience to recognise this and did not enlist more senior help.

A year or two (or three) on the wards, helping the registrar admit patients in ED, reviewing recently admitted patients on the wards after they have been diagnosed and a plan made by someone more senior, doing post acute ward rounds and learning how to do procedures before finally being the first to assess an unwell person fresh into the Emergency dept, is this really such a bad thing? Is it really going to make a worse, stupider, less experienced doctor at the end of the day?

No. It won’t. It is true, their experience will be gained at a slightly slower pace, but also at less of a cost to patient care and to the doctors themselves. Ok, the thought of being an SHO in Ireland currently for more than is absolutely necessary makes most people break into a cold sweat, but if you worked humane shifts and had adequate staffing levels and holiday cover like one does Down Under, it would be quite alright really. Here the registrar is required to review each and every patient the house officer admits. All referrals from GPs and ED go through the registrars. It again, is a much less error prone system of admitting acutely unwell patients, and less stressful for the doctors too. Even the registrars.

6) The general surgeons should introduce team briefings at the outset of each theatre list where the day's patients are reviewed, and the list order is indicated per theatre (for parallel lists), and conduct a 'surgical pause' at the beginning of each case:

I’ve never worked in surgery really. I am friends with an orthopod who tells me they have meetings like this for the orthopaedic cases every morning here in NZ. They happen really, really early in the morning, like surgical meetings are wont to do. I don’t know whether they had them or not in Ireland routinely. It sounds like something that should be done though.

7) The general surgeons should introduce weekly SpR planning meetings to agree cross-cover and plan elective work. These plans should take into account the time that will be needed to work-up patients with whom the SpR would not otherwise be familiar until the day of surgery. The consultants should be informed of the arrangements and ensure that they discuss their elective lists with cross-covering SpRs, in the same way as they would discuss the lists with their usual SpR:

Ah yes. The ‘ol “I’m on call, I’ve got the cardiac arrest bleep, I’m covering the ward patients, I’m supposed to be in theatre and I am currently also supposed to be seeing outpatients in clinic” scenario. Which actually happens ALL the time in Ireland to LOTS and LOTS of doctors. Sometimes these doctors are actually forced into covering for their absent colleagues also. At the same time.
It doesn’t take Maxwell Smart to figure out that this is not a good arrangement. The attitude is that you are supposed to cope. It is a measure of how good and how professional a doctor you are to be able to do all of this and not let any of it impact your work. In reality no-one can be in all those places, responsible for all those things, and safely provide all those services. A better measure of how good and how professional a doctor is would be how loudly they refused to do this, and how much they complained in writing, and how often they contacted their union to intercede. Anyone who is on call or post take should not be covering outpatients clinic also. Anyone who is in theatre should have someone of comparable level to hand their bleep to-or someone in theatre to answer it, relay the message to them, and someone who can take over if they really do need to scrub out and deal with something pressing.

8)The hospital should ensure that risk management processes are embedded within clinical teams, for example by establishing a clear link between specialty Morbidity & Mortality meetings and central risk management systems. The hospital has consultant sessions dedicated to risk management which is excellent practice and this role could be used to create and promote such links:

I again, have not worked in surgery in Ireland. We didn’t have M&M meetings in the places I worked in general med, at least the juniors didn’t have to attend if there were any. Most places, to be fair, had regular case presentations, and some had consultant provided teaching sessions often incorporating recent interesting cases. Many, too, had scheduled regular meetings between medics and the radiologists, to discuss and review cases, and meetings between medics and surgeons to plan surgery cases and joint management of the patients, as well as meetings with histopathologists for diagnostic information. I can’t fault the Irish system on any of this, except maybe to suggest the radiology meetings would go a hell of a lot more smoothly if everyone GOT PACS! Irish consultants by and large, are really and truly world class, and when they meet up and discuss and present things, a junior learns so so much. It’s a pity they are scapegoated so often for the error prone systems they have to work in. I hope that the proposed introduction of Clinical Directors will go some way towards improving things-not everything Mary Harney suggests is wrong after all!

Despite the Herculean efforts of the frontline staff in Ireland, the system’s inherent faults and chinks and cracks are becoming more and more evident as demand and populations increase. The level of service that they provide is not sustainable anymore with the current systems that are in place. Despite everyone’s deeply ingrained notions, deep rooted traditions and ways, and fear of change, something has to give. A child was harmed because of error prone systems that are central to the way in which hospital care is delivered in Ireland. It is a wonder more have not been. I sincerely hope these recommended changes are implemented. I will watch this space with interest.
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