How the blocks of our health system crumbled to dust

The catalogue of failures at Tallaght Hospital are management as much as medical errors, but the entire health service can learn a lot from the stringent standards of the aviation industry, writes Dr MUIRIS HOUSTON, Medical Correspondent

ACCORDING TO yesterday's edition of The Irish Times, a member of the board of Tallaght hospital said it was being "hung out to dry". Claiming the issue of unreported X-rays and unopened GP referral letters had been "solved", the unidentified member said: "The question is, why is someone trying to damage the hospital at this stage and hanging us out to dry?"

For anyone who appreciates the gravity of the revelation this week that Tallaght hospital had a five-year backlog of some 58,000 unreported adult X-rays and a stockpile of unprocessed referral letters from family doctors, the board member’s attitude will cause a shiver to run down their spine. It goes right to the core of what this sorry saga is about: a failure to appreciate the need to place patient safety at the very centre of our health services.

What we have learned this week is of an order of magnitude greater than the breast cancer scandals of 2007 and 2008. They represented poor standards, medical incompetence and caused harm to named patients. The failings in Tallaght tell us that in a major teaching hospital, one of the basic building blocks of our health system had crumbled to dust. It meant that family doctors could not reliably transfer the care of their patients to consultants at the hospital. Without a smooth and efficient interface between primary and secondary care, patients’ lives are continuosly put at risk.

Lucan GP Tony Feeney, in a letter to this newspaper, said: “We are constantly warning people (patients) to track appointments as we cannot guarantee that referral letters are opened, read or acted upon. A huge amount of a busy day is used up tracking appointments and stressing the urgent ones.” And Prof O’Dowd, the Tallaght GP and professor of primary care at Trinity College Dublin, who first brought the problem to the hospital’s attention, said: “If I write a letter to a named consultant on behalf of a patient, I expect that person or someone under his/her guidance to act on it promptly. This too needs to be part of any investigation into Tallaght’s activity. Patients who suspect that their timely referral for undiagnosed serious illness was not handled properly have reasonable questions to ask.” Significantly, he asked, “are any of our hospitals any different in their handling of GP referral letters? It is generally a black box without adequate operating procedures and a wide tolerance for ‘lost in the system’ excuses.”

It is a valid question and one for which we need a thorough answer from the Health Information and Quality Authority (Hiqa). The proper handling of patient referral has more to do with basic management than medical expertise (see panel). But no matter what the particular task, there are certain ground rules that must be met if patients are to be looked after in a safe manner.

The simplicity of any repetitive process can make it boring. In a health context, the risks posed by human fallibility when it comes to completing mundane tasks is the subject of the latest book by Dr Atul Gawande. An endocrine surgeon at Brigham Women's Hospital in Boston and a regular contributor to the New Yorker, Gawande is a key driver of patient safety internationally. In The Checklist Manifesto(Profile Books), Gawande emphasises the fallibility of our memory and attention.

We skip mundane, routine matters. The challenge faced by healthcare workers is, “making sure we apply the knowledge we have consistently and correctly”. He argues against a checklist being comprehensive or becoming a how-to-do guide. “An inherent tension exists between brevity and effectiveness. Cut too much and you won’t have enough checks to improve care. Leave too much in and the list becomes too long to use,” he says.

But we do need checklists and we have to knuckle down to using them diligently. Gawande says medicine has become the art of managing extreme complexity, with our extensive scientific knowledge exceeding our individual ability to deliver its benefits correctly, safely and reliably. Working with the World Health Organisation (WHO) and other physicians, he has devised a “Safe Surgery Saves Lives” checklist. Before a patient is put to sleep, a “Sign in” must take place, including a formal confirmation of the patient’s identity and the exact surgical site. The next stage is labelled “Time out”, when the operating team members introduce themselves and their roles before verbally confirming the procedure they are about to perform. Finally comes the “Sign out” after the operation, when all instruments, sponges and needles are accounted for. The WHO recommends that a single “checklist co-ordinator” take responsibility for confirming that each member of the surgical team has completed his or her required tasks before the operation begins.

RESEARCH INTO THE effectiveness of the 19-step checklist, published in the New England Journal of Medicine, showed that the checklist reduced the rate of major complications by 36 per cent, deaths by 47 per cent, and infections by almost half. When staff were asked whether they would want the checklist done on themselves before an operation, 93 per cent said yes. Gawande says: "Just ticking boxes is not the ultimate goal here; embracing a culture of teamwork and discipline is."

And it’s not about identifying incompetence or finding someone to blame for mistakes. The analogy between medicine and aviation is relevant. In general, airlines have a more mature attitude to safety than hospitals. Whether it is dangerous incident reporting – done in a blame-free way designed to encourage the development of improved processes before near misses turn to real deaths – or pre-flight checklists – designed not to highlight incompetent pilots but to ensure that the competent pilots don’t miss key steps in a complex environment – healthcare has a lot to learn from aviation.

Capt Ciaran Carthy, a recently retired Aer Lingus pilot and aviation safety consultant, says aviation faced similar challenges about 30 years ago. Now, he notes no pilot would fly an overweight aircraft, yet many of our hospital clinics are overbooked. He suggests that incident reporting alone is insufficient unless it is accompanied by risk management strategies. And he notes that just as pilots must be certified on a regular basis by means of simulator assessments, we now have the technology to use simulators to assess the work of surgeons and other doctors.

It is a theme taken up by Dr Tony Holohan, chief medical officer with the Department of Health and Children. If his plans come to fruition, your next hospital operation could be carried out by surgeons and nurses working to procedures currently used by airline pilots. As part of his mission to improve patient safety, the chief medical officer (CMO) has spent some hours on the flight deck of an Airbus A320 as it flew from Dublin to Manchester and back. He was suitably impressed: “The captain and co-pilot introduced themselves to each other before the flight. It was the first time they had flown together, but because the whole thing is driven by standard operating procedures [Sops], it was not a problem.”

Holohan was struck by the constant communication and teamwork, not just between the pilots but also with cabin and ground crew. He also noted the ease with which the captain and first officer exchanged roles, depending on who was flying the sector. “The cockpit resource management and procedures apply to almost everything – it defines authority and the extent of it.” Holohan sees this approach as the key to improved patient safety, whether in an operating theatre or in the community care of a person with diabetes.

A STUDY PUBLISHED in the British Medical Journalin 2000 compared how surgeons and nurses dealt with error and teamwork compared with pilots. It revealed that cockpit crews advocated flat hierarchies but surgeons were less likely to do so. But figures from Britain's National Patient Safety Agency found that although some 459,000 incidents were reported to it over a six-month period, the severity of the incidents was low; 92.5 per cent of incidents resulted in low or no harm to the patient. However, the agency noted that high reliability industries such as the aviation industry treat near misses and minor adverse events as rigorously as those that result in death or permanent disability. By addressing near misses and minor adverse events, the underlying causes can be corrected before they lead to a disastrous incident, it argues. Recently, for example, new guidance on the use of suprapubic urinary catheters and on the earlier referral of patients with glaucoma was introduced in the UK.

Will we ever see progress here? Holohan is adamant we will and points to the work of the national patient safety steering group, of which he is chairman. It is working on a legal framework that will see the licensing of all healthcare facilities. And the forthcoming Health Information Bill will put in place the legal basis for the appropriate use of patient information, including the reporting of “near miss” events in hospitals and general practice.

This has been a black week for patient safety in the Republic. Although error can never be eliminated in any human activity, let’s hope we do not see this level of incompetence again.