Dear HIFA colleagues,
This is not an easy message to write - I have not written about it publicly before. I hope that by sharing my experience it may help us understand the impact of unsafe care and that it will encourage you to share your experience.
In 1986 I was working as a junior hospital doctor doing my first job as a senior house officer in paediatrics.
One evening my registrar and I were, as usual, covering all paediatrics in five areas of the hospital: paediatric A&E, general paediatrics ward, labour room, postnatal ward and intensive neonatal care unit. I got a call to A&E to assess a 23-month-old child. The child looked moderately well but miserable with a fever. There was slight tachycardia and slight tachypnoea; no stridor or recession. I also noted slight neck stiffness. I made a presumptive diagnosis of a viral illness and recommended the child be admitted for observation. In view of the neck stiffness I could not rule out early meningitis and I called my registrar to ask him to review the child as soon as he could.
I continued working flat-out, covering the five clinical areas. An hour and a half later I received a call from the paediatric ward saying that the patient had arrived and looked very unwell. I ran to the ward, saw the child to be very ill and called my registrar to ask him to come urgently. I asked him if I should proceed with lumbar puncture in the meantime and he said go ahead - I tapped turbid CSF, appearing to confirm meningitis. The registrar arrived a few minutes later. We established a venous line and gave intravenous antibiotics, but meanwhile the child's condition deteriorated and he had a cardio-respiratory arrest. At this point laryngoscopy by the registrar revealed epiglottitis and he was unable to pass the endotracheal tube. The anaesthetist in the 'crash team' arrived and was finally able to pass a tube. The child lived but tragically had substantial brain damage.
This is the most powerful experience I have had as a doctor and it was deeply upsetting. I blamed myself for missing the diagnosis and felt ashamed. I still think about it.
So how is this a patient safety issue?
1. At first sight, it appears to be a missed diagnosis and the 'fault' lies with the health professional (me) who missed the diagnosis.
2. I subsequently learned that epiglottitis is notoriously difficult to diagnose, with as many as 80% of cases missed on first assessment.
3. Epiglottitis is very uncommon. It's the only case I saw in 2 years of paediatrics.
4. The child deteriorated greatly between when I saw him and when he arrived at the ward. The time to transfer him from A&E to the ward was abnormally long - I am not sure of the reasons for the delay but assume the people accompanying him (his parents and a nurse? or a porter?) were unable to recognise his deterioration or act accordingly.
There are wider contributory factors.
1. In the 1980s junior hospital doctors, including me, were often required to work up to 100 hours a week without days off in-between. We were often physically and mentally exhausted.
2. The level of staffing at night and weekends was inadequate to provide safe care. For example, the registrar had been unable to review the child as I had requested because he himself was tied up with urgent care in the intensive neonatal care unit.
3. NHS health policy at the time did not yet include routine Haemophilus influenzae vaccine, which was available and would likely have protected the child. In 1986 the incidence of epiglottitis in the UK was 20-30 per 100,000 per year. Routine H influenze vaccine was introduced in the UK in 1992. The disease is now exceptionally rare: less than one case per 100,000 per year.
Although I can now see the many systems factors, and recognise that epiglottitis is notoriously hard to diagnose, this was not made clear to me at the time and I was offered no counselling. All I remember was being told 'Don't blame yourself. It was bad luck. It could have happened to anyone'. This was little comfort and the experience has stayed with me.
I hope that case studies such as this can help us to understand the impact of unsafe care and how it might be improved.
I would like to invite HIFA members to share any experience you may have of unsafe care. Have you ever been involved with the care of a patient when something went wrong, something that might have been avoided? Or have you ever been on the receiving end of unsafe care, either for yourself or your family? We look forward to hear from you. Please send your contributions to: hifa@hifaforums.org
With thanks, Neil
HIFA profile: Neil Pakenham-Walsh is coordinator of HIFA (Healthcare Information For All), a global health community that brings all stakeholders together around the shared goal of universal access to reliable healthcare information. HIFA has 20,000 members in 180 countries, interacting in four languages and representing all parts of the global evidence ecosystem. HIFA is administered by Global Healthcare Information Network, a UK-based nonprofit in official relations with the World Health Organization. Email: neil@hifa.org