Medical Negligence: One error means one life
http://www.greaterkashmir.com/news/letters/medical-negligence-one-error-means-one-life/27961.html
Publish Date: Jan 22 2008 12:00PM
Error in medical practice is not uncommon and may cause harm to patient, doctor and the hospital. One persistent but preventable error is leaving behind foreign body of textile origin like sponges (gauze) inside patient abdomen after surgery. Since it readily catches media attention and lot of gossip (hence called Gossypibomas, other names are Cottonoids, Textiloma).The incidence described as 1/1300 and 1/1500 abdominal operations may not reflect the factual figures, as it is mostly under reported due to fear of medico legal implications. Complications are adherent to all procedures, but to reduce their occurrence/reoccurrence there are standards and guidelines which need to be followed. Use of only X-ray detectable sponges, the sponges to be counted once at the start and twice at the conclusion of operation and routine use of intraoperative X-ray screening in selected high risk categories. Unfortunately this practice is forgotten often and for every such incident, mercilessly, the blame is put on the Surgeon. Although actual responsibility of accurate sponge counts rests with the other theatre staff (circulating/assistant) who give green light to the surgeon to close the abdomen .This doesn’t absolve the leader of the team, surgeon, of his responsibility to ensure correct counting. Conducting regular meetings by Mortality and Morbidity committee with honest auditing, as suggested by Prof Khuroo, will definitely help in isolating the causative factors underlying specific types of errors like this. As a QA (Mortality Morbidity) supervisor, I have noticed such suggestions to improve the health care with evidence based protocols and policy procedures along with surgical audit definitely helps in the improvement of healthcare provided meetings are held regularly. The main intent is not to punish the staff but making the system accountable with continuous process of learning in reducing adverse events. This attitude encourages honest reporting of the shortcomings and issues. Could we have done better? Is there any lesson learnt from such incidents? Is there any room for improvement in management in future in similar cases? Whether we need to have changes in the structure (system) or the process (implementation), all can be effectively redressed.
Dr Fiaz Fazili
President
World Association Of laparoscopic Surgeons
Dr Fiaz Fazili
President
World Association Of laparoscopic Surgeons
