This is a story of something that happened in the middle of the night on an obstetrics ward at a large London hospital. It's a true story, told to me by a doctor who wants to remain anonymous, and who was then in the early stages of her career. Like all junior doctors, she was working ridiculously long hours. She had just one day off in every fortnight and was lucky if she cleared two hours sleep a night. She was overworked and sleep deprived. Completely standard, given the job.On this night, the doctor - I'll call her Sarah Carter - was called to the labour ward. A woman in labour, with a history of complications, had developed worryingly high blood-pressure levels. Dr Carter prepared to administer a drug to lower the blood pressure. She gave instructions to prepare the drug to the nurse at the scene, who measured out and prepared the dose, then handed the drug to the doctor, which is the standard procedure. Dr Carter administered the drug… And then all hell broke loose.
Dr Carter had asked for the recommended oral dose of the drug, but then administered it intravenously. The nurse who prepared the medicine had opened three pre-measured vials to fulfil the doctor's request. It was an unusually large amount to put in a syringe, but she said nothing. Who knows why? Maybe she was worried about contradicting a doctor. Dr Carter took the syringe without thinking - she hadn't seen the three vials being opened and hadn't realised that she'd automatically asked for an oral dose.
The patient's blood pressure dropped dramatically, and so did the baby's. The situation quickly became dangerous. It was by now 2am. Emergency telephone calls were made, the anaesthetist and registrar were woken up, dragged from their beds and rushed to the scene. The baby was in extreme distress and the ward was swarming with senior doctors. An emergency Caesarean was performed.
There was urgent work to be done helping the baby to breathe, but this time the outcome was a good one. The mother and baby were fine. Dr Carter was not. 'I was completely traumatised by the whole experience. I thought I would have to leave medicine, that I just couldn't take the possible consequences of a mistake. And I realised how easy the mistake had been to make.'
It has been estimated that as many as 33,000 people die in Britain every year as a result of medical errors or accidents. Nobody knows how many near misses there are - mistakes, like Dr Carter's, caught in time to prevent serious injury - but doctors themselves admit they are ubiquitous. Until very recently, these numbers were not acknowledged or discussed. Every accident was treated as an anomaly, a shocking and terrible one-off. The truth - that all doctors make mistakes, including the very best ones - is not what patients want to hear, but it was all that kept Dr Carter in medicine. 'I was upset and depressed about it for months, but I gradually came to realise that this was the kind of mistake that happens all the time. It wasn't a one-off caused by an incompetent - me - but the kind of everyday error that is rife throughout the whole medical system.'
That knowledge is only just hitting the rest of us. A recent spate of high profile and extraordinary cases has focused the full beam of public and media attention on medical mistakes as never before: the scandal of the paediatric heart surgeons at Bristol Royal Infirmary; the case of the surgeon in west Wales who removed the wrong kidney from his patient, causing the patient's death. Even Harold Shipman, the GP who killed at least 15 of his elderly patients deliberately rather than accidentally, exposed a reality we prefer to deny. According to Dr Ian Bogle, who is chairman of the British Medical Association, 'It's a very rare doctor who will get through his or her career without making serious mistakes. The conditions under which doctors work, and the very nature of medicine, means errors are inevitable.'
The nature of medicine means that doctors work under extreme pressure, situations are often urgent, and decisions have to be made in seconds. Under those conditions, what is an error? Removing the wrong kidney is pretty unequivocal, but medicine is an imprecise science. Sometimes we blame error for an unwanted outcome, when the error is an error of judgement, but then only with hindsight. Dr Nick Cheshire, a vascular consultant at St Mary's hospital in Paddington describes the daily judgement calls that may or may not turn out well. 'A patient presents with blocked arteries in his leg and a potential risk of developing gangrene. If we leave the patient as he is there may be a 20 per cent or higher risk to his life over the next year. If we operate, there may be a 5 per cent risk to his life - but that's tomorrow morning; 5 per cent may not sound like a high risk, but if you or a member of your family is one of those 5 per cent, that's 100 per cent as far as you're concerned.'
The government and the General Medical Council (GMC) are rushing through new legislation and systems designed to reduce errors and protect patients, which is what we all want. But there is one group of people, profoundly affected by the consequences of medical mistakes, being overlooked in this rush of reform: the doctors who make them.
Medical errors are often traumatic or tragic for patients, but they are also devastating for doctors. Depression, breakdown, leaving the profession and even suicide are common responses among doctors to their own mistakes. It's a high price to pay for the risks we ask them to take every day. Of course, we need protection from bad or incompetent doctors. But what about the good doctors, whose split-second mistakes can have equally terrible consequences? There's no helpline for traumatised doctors, no on-site counselling service or 'buddy' system where they can deal with their guilt and shame. When Dr Carter made her mistake, her impulse was to apologise to the patient 'but there just wasn't any procedure for it. I was discouraged from talking about it at all. It was made plain that I'd made a mistake and that I wasn't to make it again, but beyond that it was kind of bad form to want to discuss it. By the next day, I was expected to be over it, and to just get on with it.'
It wasn't callousness that made her superiors ignore her distress, but the long-standing tradition of silence about mistakes in medicine, driven by guilt and shame, by fear of the consequences and by the 'hero' culture in which doctors feel they can't admit weaknesses or failings, either to each other or to their patients. In an age of awesome technological sophistication, we can't accept how little we still know about our own biology or the limitations of medicine. The pressure on doctors to live up to impossible patient expectations is immense.
Sir Donald Irvine, president of the GMC describes 'the powerful collusion between doctor and patient to perpetrate the myth of infallibility', and Dr Marc de Leval, a leading cardiac surgeon, says: 'The need to perform faultlessly has created a strong pressure for intellectual dishonesty to cover up mistakes, rather than admit them.'
In March, the British Medical Journal (BMJ) devoted an entire issue to the subject of medical errors, fingering a deeply entrenched culture of 'blame and punish' as the biggest deterrent to reducing them, producing an atmosphere of fear, shame and secrecy. In one article, the BMJ describes doctors as 'the second victim' of medical error, often paying for a mistake with their mental health, marriages and livelihoods. And it's a unique pressure. There isn't another profession where mistakes are so poorly tolerated or understood, or the price paid for them so high. We may live in a global age, but we're still applying Old Testament standards to doctors. In law, or the media, there's only one response to a doctor who makes a serious mistake: name them, shame them, take them to court and if possible get them struck off. Of course, doctors have to be accountable for their mistakes. But it's a system that helps neither doctor nor patient, and does nothing to make medicine safer. According to the BMJ, 'The easy, understandable and completely wrong answer is to blame those who made the mistake.'
Faced with the human suffering of a victim and their family, it may be a natural human impulse to need somebody to blame. But it won't stop the same mistake from happening to somebody else. We can reduce medical error, but it requires a process that doesn't just involve individual doctors and the health service, but a redefining of the whole culture of medicine and the unwritten contract between doctor and patient. Sir Donald Irvine sums up a fundamental change in attitude: 'We've got to move away from picking up mistakes after they happen, to the business of asking why they happen.'
According to Matthew Pitt, a consultant at Great Ormond Street Hospital, and part of the hospital's working group on clinical risk, blaming a doctor for errors ignores the fact that many - maybe most - mistakes are the result of a series of system errors that come together with potentially disastrous consequences. 'It's common for doctors to feel that errors are entirely their own fault. Cool reflection will often bring to light a system dysfunction that has placed the doctor at risk on the front line.'
System dysfunction can mean anything from a missing set of notes to a pharmaceutical company suddenly changing the colour of the label on a drug. In Dr Carter's case, the system allowed oral and intravenous doses to be easily mixed up. The nurse was only required to check that the dosage was accurate according to the doctor's instructions - there was no check that the instruction was accurate in the first place. She was failed again by her working conditions. According to Pitt, 'The mistake when the junior doctor has been up for 24 hours is an obvious example. The overbooked outpatient clinic or operating list are other scenarios where error is more likely.'
Another young doctor describes her own most terrifying near-miss. 'When patients are nil-by-mouth they are often hooked up to a saline drip. It's common to add potassium to about every third bag of solution. I was asked to do that, only instead of adding the potassium to the bag I injected it directly into the patient's vein - 10ml of potassium chloride straight into a vein is a very good way to kill somebody.' The emergency team were called and the patient was saved, but it might easily have been otherwise. It was a standard, low-risk procedure, but the doctor had been administering injections all day, and had been on duty for 15 hours.
Reducing mistakes to the nitty-gritty detailed steps that cause them - the 'systems' approach, rather than a 'person- centred' approach is becoming the great white hope of improving medical safety. It isn't an attempt to make excuses for doctors or to release anyone from their personal responsibility. Instead, it acknowledges that all human beings are fallible, and will sooner or later make mistakes, so systems must be designed that prevent these mistakes from having disastrous consequences. If errors are predictable, they become preventable.
The person-centred model - which views doctors as 'choosing' between safe and unsafe behaviour - dominates medicine, and has produced the blame and shame culture. Writing in the BMJ, Professor James Reason, the world's leading authority on human error described it as an approach that is only 'likely to thwart the development of safer healthcare'. In a systems approach, he argues, the focus is not on who made the mistake, but how and why the defences designed to prevent it have failed. It's based, he says, 'on the assumption that we cannot change the human condition, but we can change the conditions in which humans work.'
Not all mistakes are fatal, but every mistake is potentially dangerous, and the possibility for mistakes - and the fear of their consequences - is present everyday, at every consultation, even the most simple and apparently straightforward. Professor Brian Jarman from the Imperial College Medical School in London was a GP for many years, and describes two stories, representative of hundreds like them, which could have led to him being the subject of a serious complaint.
'I had one patient, a young woman. I found her behaviour to be somewhat seductive and inappropriate - just the alarm bells of experience. She seemed to me to be requesting an unusually high number of vaginal examinations, and I thought it best to discreetly warn the other members of my practice. Unfortunately, the warning didn't reach our most junior member in time, and sure enough, he found himself the subject of a very nasty complaint for sexual misconduct. It was absolutely traumatising for him, but luckily the complaint was thrown out when it was discovered that she had made something like 27 similar complaints over a very short period of time.
'In another case, a lady came to see us to have her ears syringed before going on holiday. The practice nurse did it, although she wasn't really supposed to without permission from a doctor. While on holiday, this lady had her ears syringed again. Later she developed an ear infection, and her union recommended she sued me, as her GP, for causing the infection. Even though I'd never even treated her, I was held responsible.' The patient declined to complain for common-sense reasons, but others don't.
Complaints against doctors can take from one to 10 years, and although the complaints procedure was improved in 1996 it remains difficult and unsatisfactory for most patients, and an ordeal for most doctors - whether they are found guilty or not. One GP from the Midlands describes his experience of a recent complaint. 'I had a patient who was a 97-year-old woman. I visited her at home as she was complaining of back pain - it was likely to be caused by one of two things: a collapsed vertebrae or bone cancer. In both cases, there is no instant or obvious treatment. As I was going on holiday the next day, I arranged for a very good locum to visit her within a few days. In that time, the patient developed a cough and a chest infection, which eventually turned into pneumonia. She was admitted to hospital, but she sadly died.'
Her husband - 98 years old and bereft - complained that the doctor had failed to spot his wife's chest complaint, and that failure to treat it sooner had led to her death. The family made an official complaint to the Community Health Council, which took 15 months to complete. In that time, the GP carried on working 'although the stress of the complaint affected me terribly. Everybody at the practice knew about the complaint, and although my colleagues were supportive, I felt under a cloud of suspicion. I questioned my own capabilities and judgement, and tormented myself with the thought that I had somehow failed this family although I knew that I'd done all I could do, and I'd only seen the poor woman once.
'When the day of the hearing for the complaint finally arrived I was shaking, and I hadn't slept. The law, and the complaints procedure, is supposed to be neutral. But all through those 15 months I felt that the onus was on me to prove myself. We're very patient-centred, which I support, but it means the doctor feels guilty until proven innocent.' The complaint was not upheld , but the GP, with 25 years of exemplary service to his name, has been so traumatised by the experience that he is now looking for a job outside medicine.
According to Dr Gerard Panting, a GP who also works for the Medical Protection Society, one result of the fear of the consequences of a medical mistake has been the rise in 'defensive medicine'. 'Doctors end up not trusting their own judgement. If a patient has a simple headache, they may order a brain scan and a battery of other tests just to protect themselves in case that headache one day turns out to be something more serious. It happens a great deal in America, where fear of legislation is forcing all doctors to work this way, and it's happening here.' Costs spiral, and the patient is subjected to tests they don't need.
Until recently, doctors operated their own code of omertà. Prior to 1995 and the publication of Good Medical Practice, doctors worked to the principle that they should never disparage their colleagues, and should only report another doctor as a last resort, in cases of really serious professional misconduct, if then. But it is changing. As it struggles to develop legal, cultural and moral responses to its technological miracles and to adapt to the speed of those miracles as well as the pace of social change, we're struggling with it. What do we want doctors to be? Equal partners in our healthcare? Or supernaturally gifted healers? The problem for them is that we want both. They may be idolised or demonised, but doctors are no longer undisputed authorities. While we still expect them to perform miracles, patient power - boosted by a more 'consumer' attitude towards medicine - is transforming the culture of the consulting room. At the same time, a whole raft of new guidelines and legislation is being introduced, which means that doctors will be regulated at unprecedented levels. For the first time, doctors can expect to be appraised and reviewed.
The GMC's Best Medical Practice is now unequivocal in requiring doctors to report each others adverse behaviour or performance. It says: 'You must protect patients when you believe a doctor's health, conduct or performance is a threat to them. Protecting their own at any price is going the way of Doctor Knows Best.'
But there is also a new, if tentative, acknowledgement that the best way to protect patients is to support doctors. At Great Ormond Street, there is a pilot scheme called the Professional Standards Advisory Group, where any health care professional can discuss any aspect of errors or safety in confidence. Near misses can be reported, worries about colleagues can be discussed, and the good doctors who make mistakes can be helped to come to terms with them. Other hospitals are looking at similar schemes, and there is a general, if painfully slow, move towards glasnost across the whole area.
Changing the blame culture doesn't mean that doctors won't be held responsible for their actions, or that the effects of their mistakes are not fully or properly acknowledged. Every doctor I spoke to believed that it would lead instead to a more open and accountable health service.
The final factor in making medicine safer is a much wider acknowledgement of how intrinsically unsafe and imprecise it is. Diagnoses are constantly being reviewed and adapted, no two patients respond in the same way to the same treatment, diseases don't follow predictable patterns of development or healing. There is no such thing as a risk-free procedure. There will always be a paradox in talking about human error in life or death situations, as Matthew Pitt acknowledges. 'We can reduce error, and we can deal with it better, but we'll never get 100 per cent perfection. At the same time, we can never stop trying.'
• Some names and minor details have been changed
