This week's unsettling stories of misdiagnosed miscarriages further exposed the limits of our health system. Doctors must learn to deal with mistakes, and the HSE needs to up its game, writes MUIRIS HOUSTON
THE MEDIA HAS been full of unsettling stories this week of women who were told their babies had miscarried in early pregnancy, only for a second or third ultrasound scan to reveal that the baby was, in fact, fine. The cases involve different hospitals, with some incidents going back 15 years or more.
Unfortunately, the events have raised concerns about patient safety in our health system, with public confidence in the Health Service Executive (HSE) dented yet again.
Like most conditions in medicine, the accurate diagnosis of a miscarriage is made following a number of steps: listening carefully to what the patient says, followed by an appropriate clinical examination and some investigation or test. In clear-cut cases, all three steps will point in the same direction – either the baby is no longer alive or all is well and a viable pregnancy continues.
The challenge for both doctor and patient arises in the minority of cases where the diagnosis remains unclear. And, of course, the possibility of either human error or a problem with an ultrasound scanner – as we saw in at least one case this week, this piece of equipment can be faulty or outdated – can never be discounted, even if rare.
As technology in all walks of life becomes more pervasive and reliable, it is easy to forget that there is no test in medicine that is 100 per cent accurate. Even a relatively simple procedure, such as taking a person’s blood pressure, involves a number of elements, all of which can lead to error. So when undergoing any kind of investigation or medical procedure, it is helpful to remember that there is a small chance of what is referred to as a false positive or false negative result.
In other words, in the case of a woman with a viable pregnancy but no sign of the baby’s heartbeat on ultrasound, this is a false negative test because it is falsely suggesting the absence of life even though the baby is healthy and well.
But even doctors and nurses may develop an unquestioning faith in technology. Added to the rapid advances in new diagnostic equipment, it is not uncommon for a non-consultant doctor to take up a post at a new hospital where he or she is faced with unfamiliar technology. This adds to the stress of working in a different environment, and so mistakes can and do occur.
Even the most experienced consultant obstetrician makes mistakes, so the difficult experiences we have heard about this week will never be entirely eradicated.
What is most important is that when a mistake is made, it is dealt with quickly and openly, with the patient’s interests and welfare paramount.
For older doctors, this is a significant cultural change – many were taught never to say sorry as this was seen in legal circles as an admission of liability. Such an approach creates all kinds of barriers, including disengagement by the doctor, which can leave patients bewildered and anxious. Critically, it also means that patients are not told the truth, the discovery of which destroys what is left of the doctor/patient relationship.
Now both regulatory authorities and medical defence bodies advise a more open approach. In its latest ethical guidelines, the Medical Council has expanded its advice on how doctors should deal with bad news: “Patients and their families are entitled to honest, open and prompt communication with them about adverse events that may have caused them harm. Therefore you should: acknowledge that the event happened; explain how it happened; apologise, if appropriate; and give an assurance as to how lessons have been learned to minimise the chance of this event happening again in the future.”
As an apology is no longer considered an admission of liability, new generations of doctors are being taught to deal with unavoidable errors in a way that is best for patients. As well as being ethically correct, this is a far more natural way for a carer to communicate. And patients do notice. A study by Howard Beckman found that almost three-quarters of litigation after an adverse outcome was because patients felt devalued or felt they lacked information and had been misunderstood.
What those who spoke out this week said they wanted most was to prevent a similar error happening again; that, and a sense of being treated openly and sympathetically after a mistake had been made. All of this requires time and a proper caring environment. It is why the HSE must up its game if it is to stop the slide in public confidence following a series of events in which patient safety has been compromised.
