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.
Published April 30, 2019

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.

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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