Vesión en inglés del Mirador ‘Error médico mortal que convierte a una residente de Pediatría en criminal’ donde el autor analiza de forma pormenorizada el caso #BawaGarba, la de una residente de Pediatría que acaba de ser condenada a no ejercer la profesión y en cuyo fallo no se tienen en cuenta todas las circunstancias, personales y estructurales, en que se vio obligada a desarrollar su actuación, por lo que habrá que exigir una nueva cultura en la formación médica para que los residentes no se vean forzados a trabajar en condiciones inseguras.
Friday, February 18, 2011, children’s emergencies at the University Hospital of Leicester, United Kingdom.
At 10.30 the pediatric resident (“register”) in charge of the children’s emergencies, and of the entire children’s hospital, including hospital beds and the ICU, as the “consultants” were not present and the two companions of at the same level they had permission, valued a six-year-old male referred by his general practitioner (family doctor), with poor general condition, diarrhea, vomiting and dyspnea. The patient had a history of cardiac surgery, was under treatment with enalapril and had Down syndrome. With the initial diagnosis of gastroenteritis shock, the resident ordered parenteral rehydration and support oxygen. Thinking of pneumonia, he asked for a chest x-ray and a blood test, including gasometry.
The resident had a younger resident and a student and, after this case, she worked without rest attending other urgent patients. In addition, the electronic system worked badly and had to call by telephone to receive the results of analysis and other tests.
At 15.00 h. the resident examined the child’s X-ray. Such a chest x-ray had been received at 12:30 but the resident had not been notified, despite the fact that showed the presence of pneumonia. Therefore prescribed antibiotics, which were administered at 16.00 h. The resident received no information about the oxygen being withdrawn neither about the fever affecting the patient.
At 16.15 h. the resident received the tests that had arrived at 10.44 h, with renal alterations, a high CRP, pH of 7 and lactate of 11. Subsequent analyzes showed the normalization of pH.
At 16:30 the resident met her chief “consultant” in the corridor and told her the case and the analytical results, without requiring further help. At 18.30 pm he commented again.
At 7:00 p.m., the patient went to hospital beds and the mother gave him enalapril. The resident had clearly recommended not administering it.
At 20.00 there was an emergency call to take care of the patient, due to cardiac arrest. The resident went immediately and confused the patient with another in which there was order not to do cardiopulmonary resuscitation, so he suspended this activity for a few seconds until he was warned of the error and reanimation resumed.
At 21:20 the patient died (due to septicemia and cardiogenic shock).
Dr. Hadiza Bawa-Garba, the resident of pediatrics
The resident of pediatrics is Nigerian, Muslim with hijab and black. It had an excellent curriculum. She was tanned in almost all areas of pediatrics since it was her sixth year of residence. In fact, its “register” name alluded to its professional situation of great responsibility in which it is expected that she dominates uncertainty and makes sound decisions without having to bother the “consultant”, who is usually located but rarely intervenes.
The resident of pediatrics had been thirteen months of maternity leave and had just joined the university hospital in Leicester, which she did not know and of which they did not make a presentation.
The first review exempted the resident who continued working in the hospital. The second review, in court, four years later, in November 2015, sentenced her to two years in prison and one year without professional practice for “homicide due to gross negligence” (the sentence to the nurse, Portuguese, was similar but in both cases did not require entry into prison)
The resident challenged the ruling and the GMC court reaffirmed the ruling in June 2017 (the General Medical Council, GMC, is responsible for registre doctors and defending patients against their mistakes and excesses).
However, the board of directors of the GMC considered that the punishment was insufficient and, against the decision of its own court, took the case to the Supreme Court (High Court) that agreed with the suggestion of the board of directors to remove the license from doctor so she could never again work as a physician, as Dr. Hadiza Bawa-Garba
The sentence came out on January 25, 2018 and caused an earthquake in the National Health Service of the United Kingdom. Thousands of doctors signed a letter against the sentence, warning of the dangerous precedent against the safety of the patient because the judgments and legal punishments focus on the professionals not on the problems of the system
In 24 hours the doctors collected 230,000 euros to continue the judicial process and pay a new defense to Dr. Hadiza Bawa-Garba.
“As doctors, we know that any of us could be the next Dr. Hadiza Bawa-Garba” and at the time they remembered that 30% of the doctors are from non-white ethnic groups, which is not reflected in the leadership of the GMC
The system holes
In the study of medical errors, a distinction is made between systematic problems and personal problems. The key is to study the errors avoiding burdening the faults on the doctors because many times they are only part of a chain of failures, of systematic “holes” that make possible the error with damage when there are personal problems. It is the model developed by Dante Orlandella and James T. Reason (University of Manchester) in 1990 and later revised in 1995 and 1997. This model establishes that the emergence of a failure or error and its consequences, in terms of losses and damages, it owes to certain fragility conditions -active or latent- inherent in the systems, which are capable of altering their capacity to defend themselves against error. This model uses the metaphor of the slices of Swiss cheese, equating the substance, the cheese, with the defenses or barriers that contain a system to avoid that errors occur, and the holes with the conditions of vulnerability. In their approach, the authors state that when the slices are aligned, so that several holes -or conditions of fragility- coincide, it is when the error occurs. The task, of course, is to reduce these conditions and prevent them from aligning
“When a patient suffers a damage or adverse event, there is the so-called retrospective bias: everyone looks to see what happened and only see the doctor or nurse who attended him, do not see other factors that intervened so that the adverse event could occur.
The bias is like looking through a hole that only allows them to see the professional who treated the patient. You can not see the working conditions, the human and material resources, the organization,… In order for an adverse event to occur, all the defenses or barriers that should have prevented it, both human and system, must fail. The first barrier or defense of the system is the organizational one, the second the supervision, the third the unsafe conditions and the fourth the unsafe acts. The safe systems minimize the risk of damage even if there are failures in some of the defenses, since the others prevent it ”
In the case of Dr. Hadiza Bawa-Garba, the cheese was more than bored. For pointing out some holes:
1. The resident returned to work after a long maternity leave that would have required a “soft landing”.
2. Nobody explained to the resident how the hospital worked, nor how best to solve the specific problems during her duty.
3. On the day of the events, the resident was alone because the other two residents of the same category, “register”, were missing from work.
4. The category of “register” is relatively new and allows to load on residents with experience a clinical weight that facilitates savings in fees to “consultants”.
5. On the morning of the incident the head of the resident, the “consultant” was teaching in another city.
6. The “distance to authority” is enormous in the United Kingdom, so that the figure of the “consultant” was not real help for the resident.
7. The work overload of the resident is documented on the day of the event.
8. The nurses, also overburdened, did not identify the progressive deterioration of the patient.
9. The resident was involved in special urgent cases that required her direct skills such as lumbar punctures, not delegable to other professionals present.
10. The computer system did not work so that the results had to be received and claimed by telephone, directly.
11. The x-ray was not reported because there was no staff for it.
12. The information flows were deficient as seen with respect to the delivery of the evidence to the resident.
13. The orders were met late as it was seen in the interval of one hour between prescribing antibiotic treatment and administering them.
14. Caregivers often establish a safety curtain but in this case the mother administered the enalapril that probably precipitated the final aggravation.
15. The mistake of confusing the patient and stopping cardiopulmonary resuscitation was the end result of hours of work without rest, excessive responsibilities and poor diet and hydration.
A single trainee was held accountable when there were so many systemic errors in this case. We have a first victim, we cannot change his death, but we can avoid cruelty with the second victim of the error, the mother and Dr. Hadiza Bawa-Garba. Task errors by emergency physicians are associated with interruptions, multitasking, fatigue and working memory capacity. We can profit the opportunity and improve the system to avoid the same error (integrating second victims’ experiences into safety culture and root-cause analyses).
It is the medical obligation to identify the errors and their consequences. After identifying them you have to explain them, ask for forgiveness for the damage, repair it as much as possible and take measures to avoid its repetition.
Society has to accept that medical work entails errors and that such errors tend to have more to do with the system than with professionals.
A culture of safety for patients is established, avoiding the generalized criminalization of doctors and stopping the damages in domino caused by second and third victims (professionals, caregivers, etc) without avoiding the repetition of damages to the first victims (patients)
The #BawaGarba case demands a new culture in medical training so that residents are not forced to work in unsafe conditions, as recognized, for example, by the Royal College of Physicians of Ireland
1. Who among us has not made mistakes with harm to patients? http: //www.bmj.com/content/360/bmj.k485
2. “Every surgeon [doctor] carries inside a small cemetery to which he will pray from time to time, a cemetery of bitterness and sorrow …” R. Leriche. “La philosophie de la Chirurgie”. Part II, chapter I. https://primumnonnocere-edita.blogspot.com.es/2017/07/lecciones-de-un-maestro-rene-leriche.html
3. “Bank of clinical cases of errors that hurt but they teach” #siapGranada Testimonies about painful events for patients, for their relatives and for the doctors who attended them.
4. And if the circumstances are such that it is forced to work in conditions that go against the safety of professionals and patients the logical thing is to refuse to do so, stop working, make the corresponding urgent complaint in the Court and return to the post of work not to miss in presence [against what the GMC advises in the United Kingdom] http://www.bmj.com/content/360/bmj.k448 https://gmcuk.wordpress.com/2018/ 02/02 / faqs-outcome-of-high-court-appeal-dr-bawa-garba-case /? Utm_campaign = 9132068_GMC% 20news% 20-% 20January% 20% 28resend% 29 & utm_medium = email & utm_source = General% 20Medical% 20Council & dm_i = OUY, 5FQCK, HWPYSM, L1VA5,1
5. United Kingdom. Doctor in the ICU. Call to warn that there is little staff and endanger the lives of patients? Think twice! The terrible case of Dr. Chris Day. http://www.dailymail.co.uk/news/article-4503734/The-dedicated-NHS-doctor-tried-gag-destroy.html