Investigating errors in an imperfect system

Dr Pallavi Bradshaw, Medico-legal Lead, Risk Prevention at Medical Protection Society (MPS), addresses how clinical errors should be viewed and investigated to reduce the chance of repeating the same mistakes

The HSE recently revealed that there were 63 incidences since 2017 where surgeons operated on the wrong part of a patient’s body.1 The Executive’s records showed that the number of wrong-site procedures have increased each year – from 15 in 2017 to 19 in 2018, and 22 in 2019. While there could be multiple explanations for why this absolute number appears to be increasing, one thing I am confident about is these incidents are not solely down to a surgeon’s error.

It is rare that a mistake on the part of a doctor is the only reason an adverse incident has arisen. Usually, there are also failures in the system or process – but articles in the media fail to draw out the nuances of why things go wrong in a fragile and intricate healthcare system. More worryingly, even the investigations carried out by healthcare organisations following an adverse event rarely fully explores the multiple factors which led to the error and are often too quick to apportion blame to individuals trying their best in a complex and flawed environment.

In my 14 years at MPS I have sadly had to time and time again support doctors who have been singled out for blame following a clinical incident. My experience is reflected in high profile cases we have seen in recent years. We all know that the Irish healthcare system has been stretched to its limits even before the Covid-19 pandemic.

Healthcare professionals have worked tirelessly amid the trolley crisis, lack of beds and staff shortages. Given this compounded strain of working with extremely stretched resources, a culture of fear and high levels of burnout are not uncommon. Doctors should not be held solely responsible for errors occurring in these difficult environments.

‘Errors’ are made frequently by everyone in healthcare, regardless of their levels of experience or expertise. Fortunately, most errors are largely inconsequential. But when something does go wrong and an error is highlighted, it should be seen in the context of a system-induced phenomenon.

It can seem like Russian roulette as to why some patients come to harm and others not. The conclusions from the subsequent investigations can therefore also seem arbitrary. We may be quick to adopt a linear thought process, using ‘cause and effect’ to examine an incident. In fact, the term ‘root cause analysis’ is somewhat misleading as it pre-supposes there is one anchoring reason which led to the incident.

Doctors should not be held solely responsible for errors occurring in these difficult environments

Risk

We have to accept that clinical judgement is based on skill, expertise and risk-taking. The decisions that doctors make are founded on what they believe is likely to be best in the circumstance for a patient at any particular time. These decisions are often made in the context of limited time and information and taking into account factors outside of an individual’s control. Doctors take informed risks all the time, which usually pay off but on occasions they don’t. This begs the question why should we penalise the unfortunate ones when the risks do not pay off and when the outcome is likely down to a multitude of issues?

For example, I have often read expert reports criticising a doctor for not following a protocol. It would not be surprising to learn that protocols are not being religiously followed every day, up and down the country. If every single one and every single step in a standard protocol was adhered to, the system would be paralysed by the amount of time this took up. On most occasions, these calculated risks have no consequence, but when they do, criticisms are made. The flaw with such retrospective critique in a generally brittle system with adaptable individuals striving for the best, is not taking account the context of that decision and the factors weighed up, not all of which may relate to that patient.

Human Factor and Ergonomics

Since errors will normally arise from a multitude of system errors and with human factors at play, we need to change how we approach investigating them. Many prominent bodies worldwide, including MPS and the World Health Organisation, are advocating for the science of Human Factors and Ergonomics (HFE) to be applied to improve our understanding on why things go wrong in complex healthcare systems.

The HFE approach helps us to have a constructive and meaningful ‘learning from events’ process, emphasising on a ‘system perspective’ when examining any work-related issues which impact on system performance and human wellbeing, and particularly when investigating safety incidents.
These principles are more important than ever, particularly during the Covid-19 pandemic where doctors are concerned about facing investigation for clinical decisions made in good faith and in circumstances beyond their control.

When routine investigations and outpatient appointments are limited, along with a backlog of referrals, medico-legal disputes and investigations may rise in the coming years. Doctors have become scapegoats of an imperfect system, despite wanting to provide the highest standard of care to their patients at all times.

I believe that if regulators and employers were to take into account the whole ecosystem doctors are unlikely to be singled out and ‘blamed’. When something goes wrong, there is a shared responsibility which includes ‘actors’ across all relevant areas of the system, including external influences from policymakers, regulators, professional bodies and government.

We have often seen doctors punished for clinical errors and the outcome of some of these cases may have been different if investigators, experts and courts understood human factors. MPS believes that we must provide better and non-threatening mechanisms to investigate ‘error’ and to adopt the HFE approach. In the interim, while we strive to achieve that goal, a fundamental question must be addressed. “Do we need a greater tolerance of error in an imperfect system?” I think we do.

For learning resources on addressing human factors in your clinical practice, please contact education@medicalprotection.org

1. Surgeons operate on the wrong body part 63 times in Irish hospitals www.irishexaminer.com/news/arid-40194576.html