In a recent Crikey article, journalist Margaret Simons investigated how The Age newspaper came to publish a column “in error”.
Reading about the many factors and circumstances – both systemic and individual – that contributed to the error – I was again reminded of how the media and health industries have so much in common, at least when it comes to making mistakes.
I’ve taken the liberty of borrowing her article, and making a few minor tweaks, to test my theory….
How does The Hospital harm patients “in error”? Here’s how
Picture The Hospital at the end of the silly season. To be clear, picture it on the afternoon and evening of Friday 16 January, the day on which a patient suffered serious harm that, in hindsight, should have been entirely preventable.
The account below has been stitched together from half a dozen sources observing the action, although several of those who know most are not talking.
It’s not putting it too strongly to say they are devastated by the events of the last week.
This is, as hospital errors so often are, a story of cock-up rather than negligence or malevolence.
Here is the scene. Key people are on holiday, including the staff specialist, who has extended her leave by another week, leaving a hole to be filled. Other senior staff are also on holiday.
The staff are in any case depleted and demoralised — hoping for the best, yet reading daily about the demise of the hospital system. Just two days before, there had been another major report highlighting the system’s shortcomings. There are many vacant positions that cannot be filled.
In the quest for greater efficiencies, staff have been reorganised so that many are working in areas outside their expertise and beyond their levels of experience.
On Friday there was not time to think about the grim prospects for hospitals, or even to winge, because for the silly season it was a busy day – the combination of road crashes, a spike in domestic violence and a heat wave – and everyone was flat out.
Nobody in particular was thinking about the time bomb of patient X. The evening wore on; senior staff knew that X was deteriorating, but he did not get their close attention. It was only after some of them had left behind the pressures of the day, that key phrases came back to them, and alarm bells rang, that perhaps there had been several lapses in his care. The checks and balances meant to ensure quality care were, for a variety of reasons, not in place.
Very late that night – as X slipped beyond any chance of recovery – a senior doctor was alerted to the fact that there might have been a serious adverse event.
When news of the stuff-up subsequently hit the airwaves, the brown stuff hit the fan. The hospital manager returned from holiday to find the head honchos from the Minister’s and Department’s office filling his inbox, his message queue and by Monday afternoon, his office. On Tuesday the hospital published its apology.
What can be learned from all this? Evenings like last Friday occur in hospitals all the time. There is a reason one of the leading textbooks on hospital management has the title The Daily Miracle – as in it’s a miracle there aren’t more stuff ups.
So these are the events that The Hospital tried to sum up by saying the patient was harmed “in error”.
You could say nobody was to blame.
You could say everyone was to blame.
…. And thus concludes my (slightly) modified version of the Simons article.
An interesting question remains: which industry does the best job of declaring and learning from its mistakes?
The health care industry is far from perfect in this respect, but my guess would be that it trumps the media industry on this count. I’m not aware, for example, of there being “open disclosure workshops” for media managers and journalists, as there are in some hospitals.
Which is quite ironic, given how quick we in the media are to bag the health system for its failings.