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Medical Council’s Patient Safety and Leadership Conference

Between ‘20-30 wrong-site surgeries annually’

The President of the Medical Council estimates that there are between 20-to-30 wrong-site surgeries annually in Ireland. Speaking at the regulator’s first Patient Safety and Leadership Conference, Prof Freddie Wood said in Britain there were more than 300 such surgical mishaps last year.

“At the moment in Ireland, we don’t know how many wrong-site surgeries there are. Wrong-site surgeries can be absolutely prevented but I estimate there are 20-30 such incidents a year,” he said.

“What do we do about that? What do we do about problems with centre line infections? These are issues that the profession should be actively looking at and taking control of, not waiting for a crisis or media focus.”

 He was responding to criticism from the floor suggesting that the Council was scapegoating doctors and was a barrier to greater transparency, a comment that received applause from the audience.

However, Prof Wood said that the main role of the Council was generating medical standards and that the Medical Practitioners Act was passed by the Oireachtas and not the regulator. The landscape doctors now practice medicine in has changed completely and that has to be accepted, he maintained.

“When I started 50 years ago, it was blue skies… Now it’s like being in the Himalayas waiting for the next avalanche. The profession and everyone else has to accept that,” he said. “Unless we’re open and transparent with everybody, then the negative media focus will continue. And it does have to stop.”

However, Prof Wood expressed confidence that the profession can improve but added that it would have to involve a systemic improvement.

“There is no doubt, in my mind at least, that if safety became the prime professional culture from the top down, then the number of fitness to practise (FTP) inquiries that take place would more than halve. There would also be a support culture.

“With this Council over the last three years, all the postgraduate bodies have put support mechanisms in place, not just for young trainees who are under stress, experiencing difficulty with bullying and other issues, but also for Fellows and members.”

Also speaking at the conference, Council CEO Mr Bill Prasifka said that in some instances, FTP inquiries are revealing systemic reform in the Irish health service.

“Just now over the year, there have been a number of high-profile FTPs. But to me, the most important thing is that in some of these cases, we can actually demonstrate that there is reform systematically within the health services as a result of some of our cases. The health service is doing things differently and I would hate to think what would happen if we stopped doing what we do.”

Earlier in the conference, Prof Wood acknowledged that practising medicine in Ireland is very challenging, with the highest medical litigation in the world.

“The general perception is when somebody dies that it’s due to medical failure rather than as an inevitable consequence of having been born,” he said. “All too often, individual doctors are blamed for systems failure.”

He said it must be accepted that failures occur and that they can be valuable learning experiences.

“It is estimated that there are three times more surgical deaths than road deaths in the US. In Ireland, that would be around somewhere between 500-550 deaths a year from patients undergoing major surgeries. If that number could be reduced by a quarter by managing near misses or learning from failure, then that would provide huge extra resources for intensive care.”

Having a culture of examining near misses and failures will lead to a safer heath service ultimately, Prof Wood added. It would also lead to better teamwork, where all members of staff are valued.

“All too often in our society, especially my profession, you have a senior or somebody else denigrate, harass or bully the junior members that are doing all the foot soldier work and are most likely to be the most unconflicted to detect the actual mistake that’s been made.”

Speaking to the Medical Independent (MI), Prof Wood said that the long-awaited proposed amendments to the Medical Practitioners Act are still with the Department of Health and Minister for Health.

“We’re informed that they have been drafted. We have also been informed that they will probably be put before the houses of the Oireachtas early next year,” he said.

“The Medical Council has no control over that. We have given advice and certainly, amendments are being considered. I understand that consideration is being given in relation to the inquires having to be held in public but that is a political decision. We haven’t seen the final drafts.”

 He added he understands that the Council will only receive sight of the legislation shortly before it appears in the Dáil.

“There’s never any question of anyone making a further suggestion or advice on a change when a final draft comes in.”

Meanwhile, Prof Wood added that he believes the introduction of no-fault compensation in Ireland would help control the cost and consequences of medical litigation.

“The amount being spent by various groups in the State on medical litigation and settlements is enormous, absolutely enormous. No-fault compensation may contain it but I don’t think the level is now likely to fall.”

He estimated that between the private sector and the State Claims Agency, costs are approximately €250 million every year.

Importance of transparency discussed at IMC conference  

Transparency during a crisis is not only the ethical thing to do, it also helps manage the situation more effectively, the Medical Council’s inaugural Patient Safety and Leadership Conference heard.

One of the conference’s speakers, geriatrician Dr Kevin Stewart, Director of the Clinical Effectiveness and Evaluation Unit at the Royal College of Physicians, London, spoke about his experiences of dealing with a medical crisis and the impact of second victim syndrome on healthcare staff.

Dr Stewart was Medical Director at the Winchester and Eastleigh NHS Trust, UK, at the time of the tragic deaths of two women at Winchester Hospital.

Dr Stewart said that on 24 December 2007, news came to him that the deaths had occurred of two women who had delivered in the hospital’s maternity unit in the previous couple of days. Later, the same bacterial infection group, streptococcal A, was implicated in both deaths. As one of the few executives left in the hospital that Christmas Eve, he found himself managing the hospital’s initial response to the tragedy.

It was clear from the outset that both deaths were related and he was concerned that more people could be at risk. “As you will see, there was no plan for this.”

He informed the coroner, the regulator and all other relevant bodies and put together a crisis team from the people available. This team was made up of infection control, nursing, the press office and the hospital’s legal team and met twice a day. The family members were also briefed every day.

“From day one we said, ‘we will tell everyone who needs to know exactly what they need to know and will tell them the stuff we don’t know’.” This helped stifle rumour and kept everyone informed.

“We also asked our senior obstetricians to brief every woman who came into the hospital to have a baby. ‘Here’s what happened, here’s what we know, here’s what we don’t know. We don’t think you’re at risk but if you’d like to have your baby somewhere else, we can organise that.’”

After a week or so, the hospital felt it was getting the situation under control but on 3 January 2008, there was widespread media reporting of the deaths.

 “We were slaughtered by some of the newspapers,” said Dr Stewart. Some of the online reaction was also very abusive and there were even instances of people appearing outside staff members’ homes.

 “We got to the stage where our staff, me included, didn’t go out and about in town, as we would be recognised and you would be embarrassed to say ‘yes, it was me you saw in the paper’,” he said.“We realised that although we thought we were prepared for dealing with the media, we weren’t at all prepared.”

The hospital established an independent inquiry headed by an eminent obstetrician. This report was delivered to the families as promised but throughout an 18-month period there were peaks in publicity.

“Every time this came up and it came up again and again and again, people were walking around the organisation with their shoulders hunched and really ground down,” he said.

The week-long inquest was “very uncomfortable”, Dr Stewart recalled, but the hospital maintained its policy of transparency and admission of mistakes.

“The media who had been camped outside with their big lenses, were gone when we got out. Because when the coroner gave the verdict there was no controversy, no horror story.”

Following the verdict, the report was published as “we told the family we have nothing to hide and will publish every detail”.

There are many reasons not to be transparent, he said, adding that the fear of reputational damage, being treated unfairly and litigation is very real. However, being transparent worked, Dr Stewart maintained, because if the hospital had approached the situation any other way, it would have ended up in a much worse situation.

However, he did identify other areas where the hospital’s response could have been better. “In the 18 months while we waited for the inquest, we developed a media strategy and I received media training. I realised that communication techniques can be taught.”

The hospital’s biggest flaw was the absence of a plan, Dr Stewart acknowledged.

He also felt he did not recognise the distress and trauma for front-line staff, senior staff and himself. “That was my responsibility and I missed it.”

He pointed out that resources are available online to help deal with second victim syndrome, including on the Institute for Healthcare Improvement website, www.ihi.org.

Dr Stewart stressed that organisations should not treat crises as if they are a unique event, as most things can be planned and trained for. “But the underlying principle has to be complete and utter transparency.”

Whatever the event, an organisation can control its response to it and “if an organisation reacts well, you start to rebuild trust”. However, a clumsy initial response can compound the damage, and failure to learn means being condemned to a cycle of constant crisis, he warned.

Dr Stewart added that during any such event, the organisation’s priorities should be patients and families, staff and finally itself. “So many organisations start the other way around.”

There is now a legal duty of candour in the NHS “which I think is a great thing” but he added that training should be given to accompany this requirement.

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