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Hospital safety for slow learners
[ by Niall Hunter, Editor www.irishhealth.com]
Two weeks ago, at a conference on competence assurance for doctors, the Department of Health civil servant in charge of patient safety, Dr Tony Holohan, assured us that there had been a substantial improvement in recent times in terms of HSE management of adverse clinical incidents.
The Chief Medical Officer's understandable effort to reassure the public that things may be getting better after major patient safety shocks of recent years may have been a bit on the premature side.
The past decade has seen a number of patient safety scandals in different medical arenas. Each time we have been told everyone involved is learning from mistakes and oversights.
Each time the evidence for this is fairly thin on the ground as more scandals emerge and some recommendations remain unimplemented.
Two more reports into patient safety issued this week cast severe doubts on the proffered 'silver lining' message (after the ritual apologies to victims, of course) that the HSE and hospitals are absailing up the learning curve and robust systems to maximise patient safety are just around the corner, if they don't already exist.
The more cynical among us (a club with a growing membership) would say if the health authorities are really learning from their mistakes, then this is very slow learning process.
The HSE review into miscarriage misdiagnoses, where mothers were wrongly told the babies in their wombs were dead, was launched at a press conference last week attended by the review Chairman, eminent UK specialist Prof William Ledger and other leading obstetricians, among others.
All the medical experts at the launch were well-meaning and intelligent people acting from the most altruistic of motivations. However, they were batting on a sticky wicket.
Anxious not to to cause a panic among women using our maternity services, they stressed that the media should try to bear in mind that the 24 miscarriage misdiagnoses incidents revealed were very rare in terms of the huge number of births and miscarriages each year.
The media was advised to err on the side of caution when turning the dial towards 'shock horror' mode.
The media then realised it might be difficult to achieve this gargantuan feat of self-denial in the face of official apologies to the victims, the extent of deficits in the early pregnancy services revealed, the fact that these deficiencies that can literally be a matter of life and death existed until quite recently and that as yet, not all the relevant staff have been trained to ensure expertise in ultrasound diagnosis.
Then there was the almost unthinkable scenario of women who may have had viable pregnancies terminated as a result of an erroneous scan. The experts admitted that it was impossible to completely reassure these women and in truth, there is real no way of back-checking such an appalling vista.
Women have been urged not to torture themselves about what might have been, as their worst-case scenarios were unlikely, But that's easier said than done and perhaps it's easier to give such a reassurance if you are not a woman who has lost a pregnancy.
Prof Ledger expressed shock at a particular finding of the report - that four live births subsequently took place in women who had had a surgical procedure to remove what was believed to be a dead fetus, and in two other cases, women who had had these procedures subsequently had miscarriages.
According to the miscarriage misdiagnosis report, surgery was used to remove fetal tissue from the womb following a diagnosis of miscarriage in six of the 24 cases covered in the review.
The HSE's Clinical Lead for Obstetrics/Gynaecology Prof Michael Turner said while it was not a common occurrence, it was possible to have such procedures and subsequently go on to deliver a baby.
Prof Ledger said the two miscarriages concerned would have been viable pregnancies as ultrasound was carried out after the surgical procedure that showed there was still a heartbeat.
"What you cannot say is whether or not the procedure precipitated the later miscarriage. If the procedure was likely to have caused the miscarriage it would have happened almost immediately (when the procedure was carried out)."
Prof Ledger said these were likely to have been cases where time passed after the surgery, then the pregnancy turned out to be viable and then the pregnancy was lost later on. He said it could not be stated for certain that the surgical procedures caused the miscarriages.
The review report gives no detailed explanation as to the circumstances of these cases or why they happened.
Again it is very difficult to err towards the side of moderation when you hear about these things.
In the other big patient safety controversy this week, the HIQA report on Mallow hospital and on safety assurance at smaller hospitals, was unsparing in its criticism of the HSE in terms of its acting quickly on previously outlined concerns.
The report said national recommendations made in the April 2009 Ennis report by HIQA, which signalled the need for urgent action on safety oversight in smaller hospitals, only began to be addressed by the HSE in the summer of last year.
It should be remembered that the Ennis Hospital report came about following the delayed diagnoses of two women with breast cancer.
HIQA said the HSE's tardiness on implementing the Ennis report represented a "serious failing of corporate governance" which was was not acceptable, and it issued recommendations relating to the the governance and accountability of the HSE.
It wants HSE hospitals to ensure that they collect, monitor and report all activity data and wants the HSE to ensure that there are robust arrangements in place to safely and effectively manage change in clinical services.
HIQA wants the HSE to ensure all hospitals have a statement of purpose describing the service they can safely provide and to monitor the safety of these services. It wants all hospitals to have honest, open and timely information communicated to patients once adverse events affecting them have occurred or become known.
This almost beggars belief. The HSE, after all that has been revealed, analysed, explained and assured about patient safety in recent years, in 2011 has to be told by an outside agency to adopt fairly bog standard safeguards.
The HSE's response to the report stated that work had been undertaken during the past two years to assure the safety and quality of services for patients at Mallow and to address the issues raised in the Ennis report. It said the actions taken 'substantially address' the recommendations of this week's HIQA report on Mallow.
As it has been forced to do many times before, it moved to reassure the public about hospital safety.
The pattern of how patient safety issues have been dealt with in recent years is by now familiar.
Most of the patient safety scandals to date have been revealed through 'whistleblowing' or media exposure of a serious problem in a particular area of the health service.
There then followed a review report, the official apology, and assurances that things would get better, followed by questions as to why things had been allowed to get so bad in the first place, and a nagging worry as to whether there were safety issues in other aspects of the health service on which the whistle had not yet been blown.
It's a system where healthcare quality and safety is measured according to the latest scandal, and not by a proactive independent monitoring and quality control system, because such a system does not yet exist.
A feature of many of the scandal investigations is that the HSE has organised the subsequent review.
While not casting aspersions on the overall quality of most of these reviews, clearly a system whereby the provider of the unsafe service gets to decide how the adverse incidents should be investigated, and has an input into the terms of reference, timing and publication of such reports, is non-transparent and simply wrong.
The new Government's plan for an independent patient safety body, into which HIQA would be subsumed and which would have an ongoing monitoring role, is welcome, and needs to be implemented as soon as possible.
As it stands, HIQA has been proactive in investigating some hospital issues, but its role still appears to be 'by invitation only'.
Assurances that adverse incidents are rare and not particular to our health service cut little ice. The old cliche here is true - tell that to the victims.
We need a a robust, independent proactive and transparent healthcare safety monitoring apparatus that will assure us that the authorities are doing all they can to make sure our health system is as safe as it can be.
Miscarriage report shows hospital flaws
HIQA slams HSE on hospital safety
zebedee Posted:
28/04/2011 15:42 |
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Learning and Changing? HIQA carry-out hospital inspections, some of which are clearly quite damning. The people in charge of these hospitals remain in charge, despite several similar inspections. If the hospitals and and HSE were learning and changing, it would start by changing the management of any hospital given a poor rating by HIQA. Less rhetoric, excuses and fluff, more action needed. Hopefully the change in HSE board will be a positive start but we shall see! Zebedee |
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Anonymous Posted:
03/05/2011 15:02 |
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a HIQA report doesn't help unless its recommendations are carried out and the will and resources exist to do so. |
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