Medical Errors: Clinical governance as the way forward

A long time ago, during my days as a house officer in the labour ward, I delivered a young woman of a healthy baby girl. After the vaginal delivery, as is usually common, I was left alone to suture the cut made to increase the width of the birth canal. To control bleeding, doctors and midwives […]

A long time ago, during my days as a house officer in the labour ward, I delivered a young woman of a healthy baby girl. After the vaginal delivery, as is usually common, I was left alone to suture the cut made to increase the width of the birth canal. To control bleeding, doctors and midwives usually insert sanitary pads deep into the vaginal vault after delivery while making a mental note of how many pads they have inserted in. The pads are removed while the suturing process is ongoing; such that by the time we are done with the last suture, the final pad has been removed. I have done this procedure so many times, I sometimes brag that I can do it with my eyes closed.

On that day, after I had finished with the woman, cleaned her up and discharged her, I left to collapse on the narrow bed in our hospital room. Just as I was drifting off into the blissful abyss that is sleep, something tugged at the edge of my subconscious. 

‘Fatima, Fatima’ my mind said.

‘Leave me alone’

I refused to wake up but instead drifted into a fitful nap. While sleeping, I dreamt someone or something, I cannot remember, was chasing me around the hospital trying to catch me. I ran and jumped over fences, but I was no match for his Usain Bolt speed and he soon caught up and pinned me to the ground. I was shrieking and screaming, preparing my mind for the worst when he lowered his mouth to my ear and whispered: How many pads did you remove from that woman? Two or three?

I sat up, wide awake, sweating, despite the AC blowing at full blast.

How many sanitary pads did I really remove? Two or three? I could not recall. I ran out of the room, eyes dried of sleep, praying I had not already come to the end of my very short medical career. I could already see the headlines: ‘Doctor loses licence after six months of practice!’ My mother would have had a heart attack.

Anyways, by the time I reached the labour ward, the woman had left. I looked through her folder and noted that I had erroneously not mentioned the number of pads inserted. Two or three? How many did I remove? Two or all three pads? 

The matron on duty gave me sound advice: Call the patient back and check. We all make mistakes. If you removed everything, fine, if not, you will have a chance to right your mistake.

I got the woman’s number from her file and asked her to return to the hospital claiming there was a form she needed to fill immediately. The poor woman returned with her husband and baby a few hours later. I cajoled her into the labour room and asked to examine her again. Luckily for me, the woman was co-operative, especially when I told her the truth. Lo and behold! I had left a pad shoved deep inside her vagina.

Alhamdulillah for our subconscious.

Since then, I have learnt to document everything. Call me miss meticulous.

In the year 2000, a man called Donald Church underwent surgery at the University of Washington Medical Center in Seattle. He was supposed to have an abdominal tumor removed. Surgeons did take out the tumor, but in its place, they left a 13-inch metal retractor. 

It took two months of pain before the surgical mistake was discovered. Mr. Church recovered $97,000 in damages. While these mistakes should never occur, this was the fifth incident in five years where this hospital’s surgeons had left surgical instruments in patients.

Earlier in 1985, award-winning Miami Herald photographer Bob East was diagnosed with corneal cancer. His eye had to be removed. East decided to have it donated to the medical school to use for medical students to study eye cancers.

While he was having the surgery to remove his eye at Miami’s Jackson Memorial Hospital, someone involved in the removal brought a vial into the operating room with the formaldehyde-like solution used to preserve the eye for science.  The surgeon had earlier drawn some cerebrospinal fluid (CSF) from the patient to be re-injected into his spine. Instead of the CSF, the formaldehyde was injected into Mr. East’s spine, rendering him brain dead. He died five days later. An autopsy showed the solution had turned his organs to stone. The catastrophe resulted in policy changes requiring no unmarked vials to ever be brought into an operating theatre.

So yes, medical errors have been occurring since time immemorial. 

Two weeks ago, news broke about a new-born baby whose hand had swollen and appeared gangrenous due to a torniquet been forgotten after blood samples had been drawn in a teaching hospital in Northern Nigeria. The news made waves on radio and social media outlets and once again the issue of medical negligence was brought to light. The public raved and shouted while lawyers convulsed in delight. Yes! Another fish caught. But, in the end what can we do about it?

Only by learning from these terrible mistakes can the medical profession improve safety. Unfortunately, the state of medicine today makes it more likely that mistakes will occur. The profit motive is often forcing doctors to spend less time with patients. Additionally, the number of patients per doctor at hospitals is increasing. Less personal care results in more mistakes. When you add Nigerians’ general nonchalant attitude and poor work ethics into the mix, what you have is a ticking time bomb.

Clinical governance is a systematic approach to maintaining and improving the quality of patient care within a hospital. It’s essentially an overarching framework covering all activities that help sustain and improve high standards of patient care. This definition is intended to embody three key attributes: recognisably high standards of care, transparent responsibility and accountability for those standards, and a constant dynamic of improvement. Health care organisations must be able to evidence that standards are maintained when putting any structures, systems, or processes in place. Improving quality should be a core value of healthcare institutions worldwide; indeed, following the Health Care Act 1999 there is a statutory ‘duty of quality’ for healthcare providers in Nigeria.

Clinical governance is composed of the following elements: 1)Education and Training:  It is no longer considered acceptable for any clinician to abstain from continuing education after qualification 2) Clinical audit: this is the review of clinical performance, the refining of clinical practice as a result and the measurement of performance against agreed standards – a cyclical process of improving the quality of clinical care. 3) Clinical effectiveness: this is a measure of the extent to which a particular intervention works 4) Research and development: A good professional practice is to always seek to change in the light of evidence-led research 5) Openness: Processes which are open to public scrutiny, while respecting individual patient and practitioner confidentiality, and which can be justified openly, are an essential part of quality assurance 6) Risk management and 7) Information Management: Patient records (demographic, Socioeconomic, Clinical information) proper collection, management and use of information within healthcare systems will determine the system’s effectiveness in detecting health problems, defining priorities, identifying innovative solutions and allocating resources to improve health outcomes.

It all sounds good in theory, right?

However, even though some of these systems exist in our medical centres, they are hardly implemented. Guidelines are not followed; incidents are swept under the carpet in hopes that they will magically disappear, and mortality meetings are hardly carried out because they have become boxing rings where the most junior doctor takes the hit.

The whole situation is sad and disheartening.

We need to stand up to our mistakes and make amends. Only from mistakes can we learn and be better.