Patients suffering preventable adverse events

Research showed that during 2009 one in eight patients in Irish hospitals experienced adverse events at an estimated annual cost of €194 million (excluding legal costs), which was 4% of healthcare budget. Prof. Oscar Traynor, Director, National Surgical Training Centre and Professor of Postgraduate Surgical Education at the Royal College of Surgeons in Ireland, told the Conference.

Prof Oscar Traynor
Prof Oscar Traynor

In addition, he said that 70% of adverse events were deemed preventable. (BMJ Quality and Safety: 9 February 2016).

Seventy per cent of these patients suffered mild-moderate events, 5% suffered moderate events, while 10% of patients suffered permanent disability and seven per cent died.

In the US, figures showed that between 44,000 and 98,000 patients died each year from medical misadventure. Medical error was the eighth leading cause of death in the US and it was costing 17 – 29 billion dollars annually

He said that in a pilot study between March 2014 and September 2015, data was collected on 233 serious reportable events (SREs) in Irish hospitals, of which 100 were associated with death.

There were 23 SREs related to surgical care, 13 to retained foreign objects, five involved operations on the wrong site, the wrong operation or an operation on the wrong patient, while four were intra-op/post-op death.

“These are truly shocking figures. The risk of adverse events is higher in surgical patients and, apart from the deaths, the €194 million estimated annual cost of adverse effects in Irish hospitals is equivalent to the entire annual budget in a large teaching hospital.

“Very few of surgical errors reported are related to lack of knowledge but more to professional performance, teamwork, leadership and crisis management. These are the things that make the difference to patients.

Prof. Traynor said: “Professionalism is the central component of our contract with society. It is a key part of what makes us a profession. Professionalism is at the heart of being a good doctor. Unfortunately professionalism is more noteworthy when not present. In Ireland, we have had more than our fair share of adverse instances caused by poor professionalism and lack of teamwork. Public confidence in our patient system is at an all time low.”

He said it also raised the question as to how we should train the next generation of young doctors, particularly surgeons.

Until relatively recently surgeons had undergone a lengthy training period of 12 – 14 years during which they worked 80 hours a week or more, meaning that they spent about 45,000 hours in training.

Now the number of years spent in training had been reduced and the shorter working week, introduced as a result of the European Working Time Directive, meant that young surgeons spent less than 17,500 hours in training – 60% less than ten years ago.

The inevitable consequences were decreased operative experience and a diminution of the trainer/trainee relationship, which resulted in a loss of the role model effect.

“Role models play a very important part in determining our lives. It is a very important determinant of human behaviour and so with surgery, but reductions in hours and years of training make it much more difficult than in the past.

“As healthcare professionals we all work in a complex environment where complex interactions take place between human beings and between human beings and machines, and the potential for adverse events to take place is enormous and the way we behave when those take place has a huge effect on clinical outcomes.”

He said that in the aviation industry in 1970 it was estimated that almost three quarters of air accidents related to pilot error and human factors.

In a pilot study between March 2014 and September 2015, data was collected on 233 serious reportable events (SREs) in Irish hospitals of which 100 were associated with death.

He cited a horrific air crash on March 27, 1977, when a bomb explosion at Gran Canaria Airport, the threat of a second bomb, caused many aircraft to be diverted to Los Rodeos Airport in Tenerife. These included a Pan Am flight from San Francisco to Gran Canaria and a KLM flight from Amsterdam to Gran Canaria. Neither of them should have been in Tenerife.

At Los Rodeos Airport, air traffic controllers were forced to park many of the airplanes on the taxiway, thereby blocking it. Further complicating the situation, while authorities waited to reopen Gran Canaria, a dense fog developed at Tenerife, greatly reducing visibility.

When Gran Canaria reopened, the parked aircraft blocking the taxiway at Tenerife required both of the 747s to taxi on the only runway in order to get in position for takeoff. The fog was so thick that neither aircraft could be seen from the other, and the controller in the tower could not see the runway or the two 747s on it. As the airport did not have ground radar, the controller could only find where each airplane was by voice reports over the radio.

The KLM Captain couldn’t see the other ‘plane and believed he had clearance to take off due to misunderstandings between his flight crew and ATC. Both planes crashed and 588 people died instantly.

The KLM Captain was an experienced training captain and KLM had a good safety record. The major cause of the disaster was a breakdown in communications and command/leadership conflict.

Prof. Traynor said this showed how even experts had bad days and there were things which impinged on performance which were not related to expertise but to human performance.

He asked if similar factors could apply in an Irish operating theatre. He suggested a situation where a surgeon came in to find his or her normal operating theatre was not available. The theatre operating manger got another theatre but the surgeon was in an unfamiliar operating theatre and did not have the normal team. The surgeon was already overbooked so there was more pressure with the delayed start. As the time went on the anaesthetist was not happy with a patient and at 3.30 pm, the theatre manager comes back to say she would have to cancel the last two patients as no staff was available to work after 5 pm.

“Healthcare professionals work every day with ingredients of the Tenerife air disaster, yet our training does not train us to deal with human components.”

Very few of surgical errors reported are related to lack of knowledge but more to professional performance, teamwork leadership and crisis management.

Prof. Traynor said the RCSI had developed, and was developing in the current year, a number of initiatives to deal with the human factors in patient safety.

This included a two year part time M.Sc degree in human factors in patient safety for medical doctors, nurses and allied health professionals, which they had been running for some years. It included a small amount of didactic teaching but most was simulated and, in their most senior years, trainees were assessed in a mock operating theatre.

The RCSI was also undertaking further initiatives in the current year, including an on-line professional course and in situ team training.