Coventina's Column

Adverse events are known to occur between 3.8% and 17% of hospital admissions, with many being caused by error. A recent study (British Journal of Surgery 2011;98 [11]) investigated the incidence of iatrogenic errors and the feasibility of setting up a registry for recording them. Errors were recorded prospectively in 12,121 patients admitted to the surgical ward. In all, 16.1% of patients studied sustained a complication, with 6.1% having an error recorded.

Of the 873 recorded errors, 69.5% were of minimal importance clinically, 25.2% required intervention, 4.7% led to permanent injury and 0.6% caused death. The authors sensibly concluded that since only a small proportion of these errors led to death or permanent disability, the majority might not be recorded and thus lessons may not be learnt from them. A registry for all errors, which was regularly studied by all clinicians, might well help to reduce the risk of recurrence of errors.

Coventina concurs with these thoughts since, in her experience, although most errors may be avoided by due diligence, doctors are human and fallible, and it is easier to avoid pitfalls you know about than those you do not know about.

Leading on from this, Coventina suggests that medical honesty to patients is always the best policy when mistakes have been made. She recalls being told in her first week of anaesthetics training about two similar drug administration errors being made in the same month at the maternity hospital. The neuromuscular relaxant suxamethonium, which paralyses the patient's muscles (including those of respiration), is packaged in similar boxes to the drug syntocinon, given routinely to mothers post caesarean section. Seemingly, two different anaesthetists had mistakenly administered sux instead of syntocinon to awaken mothers having caesarean sections under spinal or epidural anaesthesia. The results in both cases were similar and traumatic for the patient – a sudden inability to breathe or move despite full awareness, with death being averted only by rapid institution of ventilator support. In one of the cases, the anaesthetist involved apologized profusely postoperationally to the patient, taking full responsibility. In the other, the anaesthetist airily informed the patient later that she had had an adverse reaction to a medicine. Only the second sued.

Coventina herself recently broke her patella in France. The Accident and Emergency (A&E) doctor failed to take an X-ray and so an infected haemarthrosis developed, delaying surgery for a week and contributing to much increased complication in the way of subsequent infection, prolonged pain, the need for further operations such as wound lavage and expense. The night the X-ray was finally done, over 48 hours later, the A&E doctor came to see Coventina to apologize personally, ensuring that your correspondent felt no ire or litigious feeling whatsoever, and only benevolence and sympathy for the individual concerned. By way of contrast, Coventina has previously won a substantial settlement against a private London consultant, who was shown by Coventina's tenacity to have lied egregiously and repeatedly about severe complications, and who ignored repeated pleas to deal with them. Even the most gentle of sprites may be driven to litigious rage by clinicians who are not only negligent but who lie about it. Clinicians, you know the best policy – follow it.

Still on the subject of risk reduction in non-cardiac surgery, a recent article (The Lancet, Early Online Publication, 6 October 2011) discusses the recommendations made by a report published at the end of September 2011 by the Royal College of Surgeons of England, titled The Higher Risk General Surgical Patient: Towards Improved Care for a Forgotten Group. The authors of the report concentrate on patients with a 5% risk or higher of surgical mortality, and discuss the importance of assessing those factors leading to a higher risk of death, namely increasing age, presence of other illnesses and the need for major or urgent surgery. The report makes nine main recommendations, including careful risk assessment of each patient, early and immediate intervention by senior doctors with skills matching the patients’ needs and prior selection of optimal postoperative care facilities.

Coventina breathes a sigh of relief that the days of penalizing trainees for asking for senior guidance with potentially dangerous procedures and conditions they have never previously dealt with are well and truly over.

Although intellectual musing was not foremost on Coventina's mind when she broke her patella in France, she was interested in experiencing the health service of another country. A recent article by the renowned economist John Appleby considers the criteria taken into consideration when assessing health care in different countries (BMJ 2011;343:d6267). Without commenting on causality, Appleby notes the strong correlation between spending per capita and quality-of-care ranking. From Coventina's limited experience and understanding, as a consumer, given similar levels of medical and surgical expertise, higher health spending almost inevitably leads to a better patient experience in terms of short waiting times, higher staff numbers in clinics and on wards, predominantly single rooms with en suite, working radiators and nutritious food: even the difference between being an inpatient in the National Health Service (NHS) in Scotland, with its more generous health budget compared with England, is apparent in terms of far less crowded conditions on wards in Glasgow compared with London's NHS. (Of course in some countries, notably the USA, health spending is bloated too by less desirable factors such as unnecessary tests to pre-empt extortionate rates of litigiousness and by private health insurance costs.) But Appleby also points out that these comparisons between countries have limited application for policymakers and that assessing health care is complex, since different countries perform well on individual aspects. Coventina is pleased to report, with especial gratitude to Glasgow hospitals, that her NHS experiences have been overwhelmingly positive: there is no doubt in her mind that clinical excellence radiates from the NHS, and despite the frustrations of easily solvable problems such as understaffing, inadequate numbers of cleaners who are not part of the ward team and inadequate bed numbers, these high clinical standards and the overriding kindness of most staff must surely be the most important factor.

With multiple sclerosis being more common in Scotland than anywhere else, Coventina is heartened to hear about a new disease-modifying drug, teriflunamide, which has been shown in a trial to help sufferers with the relapsing form of the disease (N Engl J Med 2011;365:1293-303, 6 October 2011). The randomized study involved 1088 patients who had experienced at least one relapse in the previous year or two, over the previous two year period. Teriflunomide was shown to significantly reduce the number of relapses, magnetic resonance imaging evidence of mass spectrometry activity and progression of disability compared with placebo.