LITTLE Nashwa, merely nine-months-old, died last month due to a tragic medical error: being given an incorrect dosage of a concentrated electrolyte. It was given by a staff member who should probably not be administering medications in the first place, let alone that of a high alert medication.

The emotional response of Nashwa’s parents — and her father’s pleas for action to prevent similar tragedies — is all too natural. Civil society offered support, and the electronic media highlighted the case at every level, resulting in the arrest of the duty doctor, nurse in-charge and administrator of the hospital. Politicians and celebrities attended her funeral, expressing solidarity with the family. All this can help provide emotional support to the bereaved family at this crucial time, but it cannot bring little Nashwa back. And, sadly, this will not be the last case of someone’s precious one dying due to a medical mistake.

In 2001, at one of the world’s best hospitals (Johns Hopkins), 18-month-old Josie King died of dehydration and a wrong dose of narcotics. Her parents underwent the same trauma as Nashwa’s parents and wanted to punish the hospital. “How can they get away with this? They must suffer. They must honour her memory. They must be responsible. They must feel the pain that we feel,” wrote Josie’s mother Sorrel King.

Nashwa’s senseless death was the result of a broken system.

Sorrel and her husband embarked on a mission to make hospitals safer places for other children. They went back to the very hospital they considered responsible for their daughter’s death and tried to improve it through a programme later named the Josie King Patient Safety Programme. They found a partner in Dr Peter Pronovost at Johns Hopkins, and together began identifying safety problems and devising ways to prevent them. The initiative grew into the Josie King Foundation, with multiple programmes helping the health system across the US, including patient safety curriculum development and awards for nurse-led patient safety projects.

Medical errors are a leading cause of death globally. In Pakistan alone, an estimated half a million people die due to preventable medical errors. Most of these errors are made by studious healthcare workers stuck in a broken system. Unfortunately, it is only those on the front lines of this system who face the brunt of the punishment. Those responsible for the dysfunctional system in the first place get away with it.

Even if those arrested for little Nashwa’s death are awarded the strictest punishments possible under the law, it will not prevent future errors. The broken system will place another healthcare worker in a similar situation, leading to the same kind of error reccurring.

To truly prevent such events in the future, we need to accept that Pakistan’s healthcare system is broken and thus needs fixing. We must accept that, until it is fixed, it will remain highly unsafe for patients, and many will likely die from preventable medical errors. All the architects of the current health system — medical schools, nursing schools, hospitals’ management, health ministries, regulatory bodies, and healthcare commissions — have their own unique responsibilities to prevent such harm by working towards improving the system.

Medical and nursing colleges must introduce patient safety as an integral part of the curriculum, in line with international guidelines as proposed by WHO. Health regulators in the form of healthcare commissions must not only start playing their roles in licensing those healthcare establishments that meet the minimum criteria, but also act as technical resource centres for improvement initiatives.

In a majority of Pakistan’s hospitals, there are well-trained doctors and nurses who know their jobs well but are only human — they need help to implement systems that are safe and protect patients against inevitable human errors. Through the Sehat Insaf Program­­me or other private insurance programmes, hospitals must be mandated to meet quality standards and performance on patient safety indices to be enrolled as service providers. These initiatives can start from basic reporting of quality and patient safety data for comparison purposes, and can go up to supporting healthcare establishments for electronic health delivery platforms.

Lastly, public health institutions must also be brought into this net of accountability and be compelled to improve — not only through infrastructure, but also through safer processes. Many lives are lost in public hospitals due to medical mistakes, only for things to go back to business as usual once the bereaved families have stopped protesting. A national roadmap for prevention of harm from medical errors is the need of the hour.

Between Nashwa’s death and the writing of this article, at least 3,000 more patients may have lost their lives in our health system due to preventable medical errors. The time to act is now.

The writer is a US-certified professional in healthcare quality and patient safety.

Published in Dawn, May 5th, 2019