When a series of procedural holes lined up

ANALYSIS:Medical errors such as that experienced by Baby X rarely occur as a result of a single factor

IN ABOUT 10 per cent of hospital admissions, some form of adverse outcome occurs. Most of these are not due to clinical error, but are the result of known side-effects of a treatment or operation. In this case the inquiry has highlighted both the human and system elements that can combine and result in a standard of care below what a patient has a right to expect when admitted to hospital.

The finding of three counts of poor professional performance by a Medical Council fitness-to- practise committee against a former senior surgeon at Our Lady’s Children’s Hospital in Crumlin again puts a focus on adverse outcomes in healthcare and how they might be prevented.

Significantly, the chairman of the inquiry also raised concerns about procedures at the hospital, citing “significant evidence of systems failures, weaknesses and errors” in surgical procedures.

There had been a failure to instigate the “surgical pause” policy, in advance of the procedure, he said. This is a reference to a World Health Organisation mandated checklist designed by a leading patient safety advocate, Dr Atul Gawande of the Brigham and Women’s Hospital in Boston.

Gawande devised the 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 the time-out or “surgical pause”, 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 team has completed his or her required tasks before the operation begins. Research into the effectiveness of the 19-step checklist shows it reduced the rate of major complications by 36 per cent, deaths by 47 per cent, and infections by almost half.

Patient safety experts have described a “Swiss cheese” model to explain how medical error can occur. There is seldom a single factor involved; more often a series of holes must line up before the error can be completed. For example, a surgeon may be tired and distracted by other patients before he delegates a procedure he had planned to do himself. When added to an administrative error describing the wrong operation on a theatre list, a series of factors line up, leading to an error such as that experienced by Baby X.