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Nashwa’s death is tragic. What can be done to prevent such incidents?

A system that seeks to penalise individuals without analysing the faults within is doomed to perpetuate the same errors.

Updated May 27, 2019 04:50pm

Nine-month-old Nashwa’s tragic death at the Darul Sehat Hospital in Karachi recently has once again put the spotlight on our disaster-prone healthcare system.

According to reports, the child was administered a lethal dose of a very commonly used electrolyte. The reported mode of delivery was incorrect, since potassium chloride is only given very slowly through a drip. Several significant matters have emerged from this incident, including the quality of training, if any, of the involved doctors and nurse.

We don’t intend to speculate on the various aspects of this case (official investigations haven’t concluded yet); instead, we want to take a step back and look at the larger picture. This is necessary as Pakistan seems to be stuck in a never-ending cycle of medical mishaps and protests, followed by hasty investigations and scapegoats — until the next disaster.

Editorial: Medical malfeasance

Any avoidable loss of life in a healthcare facility is a matter of utmost concern and requires an impartial investigation and an appropriate response. Blindly condemning healthcare professionals, getting First Information Reports registered against perceived perpetrators and sealing the erring hospital will do nothing to prevent such incidents from happening again.

In fact, as has been well-documented, such measures lead to much broader harm for not only the health profession, but for society in general. It is imperative, then, to take a more nuanced approach in order to analyse what ails the healthcare system.

Inherent risks

Dispensing healthcare has risks. Adverse events, which are injuries occurring as a result of unintended or undesirable acts of medical treatment, are part and parcel of the profession.

Medical errors result because of the “failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim.” They remain the third leading cause of death in the United States over the past decade, while in Europe, a World Health Organization report notes an incidence of 8-12 per cent medical error-related adverse events in hospitalised patients over the last two decades.

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The Journal of American Medical Association concludes that “errors must be accepted as evidence of system flaws and not character flaws.” A seminal report by the Institute of Medicine also recognises medical errors as an inherent part of medical practice.

This does not, of course, mean that such events should be accepted as fait accompli. They need to be investigated to find the root cause so that future events may be prevented.

The Institute of Medicine recommends designing safer health systems so that mistakes are harder to make, as well as instituting reporting mechanisms to identify the shortcomings so that preventive measures can be devised and implemented.

Negligence vs malpractice

It is important that those who are commenting on and covering healthcare-related events be cognisant of these different yet closely related terms.

Medical negligence is the failure of a healthcare professional to provide care that would be reasonably expected in a certain situation, or the act of doing something that a reasonable healthcare practitioner would not do. Leaving a swab or an instrument in the abdominal cavity after an operation or not following the protocol of giving a certain medication falls under this definition.

Events such as these are entirely preventable because there are standard protocols and checklists available, following which such events ought never to occur. Many such events are called never events.

These protocols are part of standardised medical training. But in Pakistan, with huge variations in the level of training of various cadres of healthcare professionals, never events keep occurring — indicating a major system flaw.

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Whereas medical errors may often reflect unacceptable incompetence or carelessness, they are not intentional or premeditated.

Medical malpractice, on the other hand, is improper, unskilled or negligent treatment of a patient by a healthcare professional with a malafide intent, which may include personal or financial gain. Unnecessary medical tests or referrals to colleagues, or unindicted surgical procedures come under this category.

It is due to lack of intent that acts of medical error are generally not regarded as criminal, in contrast to malpractice which is considered a criminal act since there is intent.

Whatever the nature of the incident, and however horrific the outcome, the only reasonable way forward is to report and investigate. While one major objective is to ascertain the exact facts of an incident, another equally important aim is to draw lessons so that it can be prevented in the future.

Reforms, not reprisals

Initiating criminal proceedings against a doctor, while able to momentarily appease the mob worked up into a frenzy, is detrimental in the long run.

This kind of action against doctors prevents further reporting of such events because of a very real possibility of reprisal. It also makes experienced clinicians reluctant to accept critically-ill patients under their care for fear of losing the patient and the accusations that may follow.

In the US and United Kingdom, a case against healthcare professionals can be filed for incidents of negligence in order to seek compensation. Arrest of a healthcare professional only occurs in a situation of criminal malpractice or fraud with an intention to harm. But before any arrest, there needs to be robust evidence against the individual.

According to an article looking at the Australian healthcare system, “criminalisation without adequate support for reporting, complaint resolution, and accountability and transparency creates a culture of fear and cover-up within health care.”

Closer to home, an Indian court has clearly identified the negative impact of criminal prosecution of healthcare professionals by stating that “doctors will not be able to save lives if they were to tremble with the fear of facing criminal prosecution”.

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Indian law provides some level of immunity to healthcare professionals in criminal court only. It states that “doctors accused of rashness or negligence may not be arrested simply because charges have been leveled against them; this may be done only if it is necessary for furthering the investigation, or for collecting evidence, or if the investigating officer fears that the accused will abscond.”

Both Sindh and Punjab Healthcare Commissions also state that “no suit, prosecution or other legal proceedings related to provision of healthcare services shall lie against a healthcare service provider except under this Act.”

These acts also make healthcare organisations responsible for the legal protection of their employees as stated in section 16(b): “Doctors and healthcare workers should have legal protection and in case of litigation, the administration must own the responsibility of legal cover and provide full financial and legal help accordingly”.

These systems in no way indemnify healthcare professionals of wrongdoing. Physicians need to be held to standards higher than those for the rest of the society. In case of an adverse event, full and honest disclosure followed by an apology is considered the minimum.

Failure to disclose amounts to improper, unethical and negligent behaviour. Compensation is a gesture that conveys the acknowledgment that a healthcare organisation has a duty of care towards those it has harmed.

Learning from mistakes

Healthcare providers, like members of any other profession, often falter. If harm is not the intent then, more often than not, it is a flawed system that creates opportunities for mistakes to happen.

A system that seeks to penalise individuals without analysing the faults within is doomed to perpetuate the same errors.

In the famous Libby Zion death case in New York in 1984, investigations found that the death occurred due to an error made by an exhausted and overworked resident, who was required to be on duty without sleep for 36 hours.

This led to the Bell Commission and the rationalisation of work hours. Had the erring resident just been fired or put behind bars, the system would have remained flawed and patients would have continued to suffer at the hands of exhausted trainees.

In order to address our often fatal flaws, it is recommended that a multi-pronged approach be employed involving a national focus on patient safety, identifying and learning from errors by creating safe and reliable reporting mechanisms along with raising performance standards at healthcare organisations to improve safety systems.

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A mandatory reporting for all adverse events and voluntary reporting of errors needs to be instituted. Analysis of these reported events can lead to a rise in standards and implementation of safety systems within hospitals. Anonymised reporting of errors has been a successful tool to enhance reporting and devise preventive measures.

Monitoring bodies such as the Healthcare Commission and Pakistan Medical and Dental Council should take the lead in implementing these.

Unless errors are reported, we will not be able to devise ways of correcting their cause. And unless people feel safe to report, much of the iceberg will remain hidden, ever so deadly.

If sealing hospitals is the acceptable response to such incidents, then given the stories we read in the papers and on social media, can we expect even a single hospital to escape this fate?

We have to move away from knee-jerk responses and rectify the structural problems that lead to disasters.


Are you working in Pakistan’s healthcare sector? Share your insights with us at prism@dawn.com

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Nida W Bashir is an associate faculty member the Centre of Biomedical Ethics and Culture at the Sindh Institute of Urology & Transplantation.

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Aamir Jafarey is a professor at the Centre of Biomedical Ethics and Culture, SIUT


The views expressed by this writer and commenters below do not necessarily reflect the views and policies of the Dawn Media Group.

Comments (22) Closed

Abdul Muqtadir
Apr 30, 2019 05:28pm
Doctors must be held accountable for Medical Malpractice.
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bhaRAT©
Apr 30, 2019 06:18pm
The problem is giving and getting injections and drips has become a habitual vibe. When drugs cab be administered orally, injections should be discouraged. Drug given orally can be pumped out and hence a better chance of saving life. Injections are rarely given in most countries.
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Munaza Khan
Apr 30, 2019 08:39pm
Excellent read! I had similar concerns when I read about the tragic loss of Nashwa. It is a system failure. Many times due to over work doctors can make mistake. Pharmacy and Nurse are suppose to double check the order before giving it to the patient.
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Dr Fayyaz
Apr 30, 2019 08:58pm
Apt analysis. Closure of healthcare entities, filing of FIRs and excited media stories are something which will not help. It is a very daunting task even to make healthcare professionals understand the real way to handle such situations and preparations involved; society in general is far behind to understand the delicate way of improvement. Press has important role to play. I hope the authors will also try to engage the urdu press as well to disseminate these thoughts.
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Jehengir khan
Apr 30, 2019 09:26pm
What can be done to prevent this kind of death? Nothing....who has time.....doctors forgot their fundamental duty.....they are looters..
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SYED FAHD ALI QAZI
Apr 30, 2019 10:00pm
This country and all of its benefits belong to the rich and elite. We all know this but still beat around the bush.
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Aamir Omair
Apr 30, 2019 10:41pm
Very well written comprehensive and objective analysis of the current situation. Need to act rationally by introducing proper legislation to prevent such unnecessary deaths due to negligence.
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J bashir
May 01, 2019 12:14am
Good piece to explain that often the fault lies with the system rather than an erring individual. It is also important to realise that errors without intent to harm is not the same as intentional harm to the patient, which is criminal Until and unless our system is imported, safety culture implemented and embraced, patients would continue to be harmed. Firing and punishing one or two individuals will not prevent repetition of the same events, unless the system is overhauled. Safety first should be our mantra, check lists, honest anonymous reporting and an enthusiasm to embrace culture of safety should be the aim
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Dr. Rafiq Khan
May 01, 2019 12:29am
It should be investigated whether the hospital staff and doctors have real degrees or fake degrees and if their degrees are real which university issued these degrees?
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skz
May 01, 2019 12:40am
Potassium chloride is a commonly used medication. Very important electrolyte which needs to be replaced for patients taking diuretic. Commonly replaced orally but in case of very low level , may need to be administered via vein but mixed in a drip form and over hours , otherwise can have heart problems. Cannot be given fast even diluted in a drip. By the way Potassium chloride has been given as Iv push and not in drip form to kill the inmates with death sentence. To avoid similar incident happened , the medication should not be made available to the person who is going to administer. In US and Europe it is prepared by the pharmacist before it is released to the nurse who administers it. I don't know how it works in Pakistan.
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Batool
May 01, 2019 01:45am
Forget nashwas, check current Thar's doctors and Govt. Sindh Medical board, where they inject hiv injecions to babies
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AB
May 01, 2019 04:09am
Informative and thoughtful article; taking the broader picture of this unfortunate incident
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Dr. Talha Vaqar
May 01, 2019 06:57am
Very thoughtful analysis of a phenomenon in our society which often charged with emotion leads to knee jerk responses. Thank you for taking the time to address this issue when it is still hot In the press.
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Afshan Khattak
May 01, 2019 09:52am
I have seen so many deaths like Nashwa that I have lost count. Pakistan is completely clueless and vision less when it comes to health and education. I am sure all departments are kaput but health is something that affects us and our loved ones. Starting from ground zero, the FSc entry to medicine upto FCPS, the highest medical degree in Pakistan, there is a jungle of irregularities, illegalities, corruption, falsification of documents, lack of implementation of rules, lack of merit, megalomaniac seniors at helm of affairs, foreign based desis thinking they know what is good for Pakistan, poorly compiled new laws wrecking hevoc in the existing cesspool and of course human greed and lust for more which multiplies by 100 when it comes to Pakistan. And I have not mentioned nursing or dispensing or ancillary services......! This is not going to change. NEVER! Unless internal reform occurs from the core outwards and from base upwards.
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Afshan Khattak
May 01, 2019 09:54am
@Abdul Muqtadir, who is being held accountable in our mumlikat e khuda dad? If any accountability is going on, doctors must be subjected to it. Don’t beat about the bushes or empty words
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saqib ghumman
May 01, 2019 11:28am
@Jehengir khan, well said
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Laila
May 02, 2019 02:01am
End corruption. Increase education and awareness about rights. Increase surveillance and monitoring. Implement accountability and ethical recruitment. Enfirce harsh punishments for culprits.
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Saima Perwaiz Iqbal
May 02, 2019 09:33am
One step in the right direction would be formation of error-reporting committees in all health care providing institutions. The purpose of these committees would be to identify the flaws in the system,propose and implement measures for prevention of future errors and not retribution.
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Dr Fasiha Sohail
May 02, 2019 05:44pm
The article captures the essence of the issue. How to react to the the matter was even more imprtant than the matter itself. The systems systematic problem is to be identified and then things could be rectified in future. This is not the solution rather it had camouflaged the issue. Look on the other aspect. Hard working daring doctors, nurses and institute will not take sick patients and medical error or negligence reporting can never be implemented in the system.
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Dr Fasiha Sohail
May 02, 2019 05:50pm
Article captures the issue to the core. The approach to respond to the issue was worse than the issue it self. How will the system improve if we kill the systematic medical error reporting by reacting in bizarre ways.
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Syed Kamal
May 02, 2019 08:27pm
Looks more like an effort to find excuses for extremely high rates of malpractice, non-enforcement of relevant laws by the provincial government, and soft peddling of take it easy approach. Every aspect of Medical practice is as afflicted with corruption and greed as any other aspect of life in this country. Who doesn't know that Doctor's receive various kinds of consideration for prescribing drugs. Nearly every drug company offers inducements (free merchandise, laptops, leased cars, junkets to attractive locations in the name of continuing education). Who doesn't know consultants who suggest only marginally useful surgery to patients to create billings. Hospitals who render unnecessary diagnostic test and leave ventilators to dead patients, doctor's who arrive late every day. Does anyone have any doubt that Medical profession is endowed with sufficient prosperity to steer policies and practices they prefer.
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Syed Kamal
May 02, 2019 08:32pm
@Afshan Khattak, You hit the nail on the head sister. More power to you. Medical professionals pretend to be pure as the driven snow but they aren't and can't be any better than the society they are a product of.
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