Two cases: one theme
Re: the articles “A rash oversight” and “A failure to monitor”), Casebook 21(2).
›› Two articles have a common theme. Patients in both cases sued their GP while the healthcare system and government policy neglected to ensure patient safety.
The healthcare industry should take steps to prevent chickenpox in pregnancy. We could have a national immunisation program [here in the UK] like that in the US (www.cdc.gov/vaccines/schedules/hcp/imz/child-adolescent.html). We could also check women for immune status at booking or preconception. As it is we rely on GPs remembering to follow a post-exposure prophylaxis protocol. Murphy’s Law applies so patients suffer and doctors pay, via indemnity subscriptions, to help clear up the mess.
Why does the healthcare system have us install a piece of electronics in a man’s chest without having a way to monitor it? The GP’s notes may have been poor but the responsibility for the device should rest with the company that made it and the clinic that inserted it. A cardiac pacemaker is a ‘mission critical’ device. If it stops the patient might die. In the case you describe recording the pulse or an ECG wouldn’t have given information about its activity over a period longer than a few seconds. There should be systems to ensure that it can’t fail without that failure being detectable in real time. At the very least there should be a way to interrogate it to determine how it has behaved in the past.
Why does the healthcare system have us install a piece of electronics in a man’s chest without having a way to monitor it?
In critical event analysis we should be looking at ways to improve patient safety. A simple measure would be to change the way we record blood pressure. The data entry box for BP using INPS Vision has no facility except free text for recording pulse rate. It would be very simple to add a mandatory field for pulse rate (and reg/irreg to screen for atrial fibrillation).
I want to see MPS analysing cases to identify areas where putting pressure on government health departments and their suppliers to change policy could prevent future disasters, and then applying that pressure.
Dr Ian Quigley, Partner and GP Principal, Western Road Medical Centre, UK
Many thanks for taking the trouble to write in with your response to two of the reports in the last edition of Casebook. It is useful for us to have feedback like this, and it informs our future publications and lobbying activities. We also plan to share such activities with readers in more detail, in future articles and updates.