Medical mistakes and human error killed a four-year-old child in a Halifax hospital. Understanding why it happened, and not just placing blame, is necessary to stop it from happening again.

by DEBORAH JONES
April, 1998, published in Chatelaine magazine

“Oh, no.”

Not again,” thought Donnalee Braund last May, her heart sinking as she listened to the radio report. A British Columbia child had died when an anticancer drug called vincristine was incorrectly injected into her spine. The details were hauntingly familiar to Braund. Five years earlier, in a Halifax hospital in 1992, Braund had held her 4-year-old daughter, Courtney, in her arms and watched as she slowly died from paralysis caused by the same medicine. It was a drug that, when injected into her veins, would heal Courtney’s cancer, but when mistakenly plunged into her spine, had killed her.

And now it had happened again, this time to a 7-year-old in a Vancouver hospital. (That child’s parents have asked that her name be kept private.) “When I heard about the death in Vancouver I couldn’t believe it,” says Braund now from her home in Yarmouth, N.S. “How could this happen?”

When medical mistakes occur, it’s tempting to look for someone to blame. The doctor was incompetent. Or the pharmacist was at fault. But more often than not, serious medical errors aren’t the result of a single mistake: they happen when a complicated series of factors come together with fatal–or near-fatal–results. And they happen more often than you might think. While Canadian statistics are difficult to come by, one recent U.S. survey found that 17 percent of patients in intensive care and surgical units suffered “serious injuries due to errors.” But even in the United States, where litigation is something of a national pastime, blaming people hasn’t stopped medical accidents from happening. Understanding why those accidents happen–and sharing that understanding with other hospitals-just might.

It’s something other industries have already learned: in heavy industry, aviation, the nuclear power business and elsewhere, risk-management experts have developed techniques aimed at analyzing tasks and preventing errors before they occur. But medicine has been slow to subject its practices to this so-called human factors analysis. And patients like Courtney Braund and the B.C. child are paying the price.

We all make inane blunders: being rushed and misdialing a familiar telephone number, feeling stressed and taking a wrong turn on a route we know by heart, absentmindedly spooning baking soda instead of baking powder into a batter. And while you’d think that the more often that we perform a task, the less likely we’d be to make a mistake, that isn’t the case. Instead, say psychologists, we stop paying attention to what we’re doing–even when what we’re doing could have life-or-death consequences. The fact is that we’re human, and humans will always make mistakes.

The solution? Make the mistakes harder to make. How? By having two people go over a checklist before a dangerous task is performed, or by designing things so they simply don’t fit where they’re not supposed to go–like gas pump nozzles for leaded fuel that are just too big for us to stick into vehicles that run on unleaded gasoline.

It’s called human factors analysis, a way of focusing on human-centred design. Or, as analyst Alison Smiley says, “It’s about understanding human limitations.” Human factors analysts (sometimes also called ergonomists) are highly trained specialists, often with backgrounds in psychology, kinesiology (the study of anatomy and movement) and an industrial or other specialized application, who design systems and procedures to reduce the likelihood and consequences of mistakes.

The discipline’s roots go back to the Second World War, when British and American psychologists and engineers were brought together to design equipment and reduce errors on military factory assembly line. The specialty was reinvigorated in the United States in the 1970s after a series of high-profile aviation mishaps. Since then, human factors analysis has become commonplace in many industries from aviation to nuclear power, where specialists help increase efficiency, reduce error rates and, especially, improve safety. Their techniques include placing barriers to reduce the danger to workers from heavy equipment, designing computer chairs and desks to reduce the risk of repetitive strain injuries, and researching the most visible color for signs on airport runways. But many people in the medical field haven’t even heard of this science of safety, and most members of the Human Factors Association of Canada who work in health care do so to advise on protecting health care workers from job-related stress and health hazards–not to protect patients from medical errors.

Dr. Peter Suedfeld, president-elect of the Canadian Psychological Association and former head of the psychology department at the University of British Columbia, is not surprised that health care in Canada has not adopted human factors analysis. “Especially when the people involved are professionals with high self-esteem, there seems to be a philosophy that they can handle whatever problem comes up and don’t need to consult psychologists or human factors experts. But had they consulted them, they could have prevented mistakes.”

Because, unlike gasoline nozzles, medical devices often do fit where they’re not supposed to go. Unlike aviation checklists that regulations decree must be filled out and approved by mechanics and supervisors, sometimes hospital checks and balances are lacking. And unlike the psychologically selected teams in some hightech manufacturing plants, medical teams very often consist of people thrown together on a moment’s notice, some of whom are distracted by having too much work on their minds or exhausted from working brutally long shifts.

It was a combination of these factors that conspired to kill Courtney Braund. On April 23, 1992, Donnalee wrote in an exuberant scrawl in her diary: “We’re so excited about our last chemotherapy treatment!” Her daughter had battled cancer for two years; doctors now considered the little girl cured of her leukemia. On that hopeful spring day, Donnalee took Courtney to the Halifax children’s hospital for her last round of chemotherapy and dental surgery to correct problems caused by her leukemia treatment. The procedures were scheduled for the same time in order that Courtney would only endure one general anesthetic. And so she was placed in the operating room, far from the cancer ward.

In the cancer unit, oncology pharmacists and oncology nurses ensure that two kinds of chemotherapy drugs–those administered intravenously into the blood and those injected into the spinal column–never even enter the same room together. But on that day in April, in a different ward, the pharmacy delivered both kinds of drugs together. The nurses in the operating room, unaware that the intravenous drug vincristine is lethal when injected into the spinal column, laid it out side by side with other syringes. There was no physical barrier–the medical equivalent of different gasoline nozzles–to stop the syringe of intravenous vincristine being inserted into Courtney’s spinal tap.

And that meant the last safety barrier was the small-print drug labels stuck on the syringes. But when the time came for Courtney’s chemo, her regular cancer doctor was busy and asked another doctor to treat Courtney. The replacement doctor was preoccupied: on his way to the operating room, he received news that one of his own patients was critically ill and was coming to hospital in an ambulance. Even though he checked the labels on Courtney’s syringes, with his mind on the other patient, the doctor methodically injected all of the drugs into Courtney’s spinal tap. Nobody noticed the error.

“Most errors result from faulty systems, poorly designed processes that set people up to make mistakes,” says Dr. Lucien Leape of the Harvard School of Public Health. Dr. Leape sits on the board of the National Patient Safety Foundation, a new U.S. agency dedicated to reducing injuries caused by medical errors. The foundation was set up by the American Medical Association last year after a series of highly publicized medical mistakes in the United States, including one patient whose wrong leg was amputated and the death of a Boston health columnist who was a victim of a chemotherapy mistake.

Similar cases have received media coverage here in Canada: horror stories such as the case of a Halifax man undergoing brain surgery who had the wrong side of his scalp incised before doctors realized their error. But there’s nothing like the National Patient Safety Foundation here. While provincial Colleges of Physicians and Surgeons investigate complaints of mistakes (and those of incompetence, which is a different issue), the colleges are not obliged to automatically make information public, nor to collect data. When patients die from mistakes, provincial coroners or medical examiners may investigate. But while coroners’ reports are sometimes public, coroners do not keep specific statistical records of deaths from medical mistakes. While there is a reporting agency for medical equipment malfunctions, there is no official agency that collects data on human medical mistakes at the national level. Reports in the media, even write-ups in medical journals–both of which were done following Courtney’s death–may be overlooked. And there is no official way to share data from other countries.

So no one at the Vancouver hospital had even heard of Courtney Braund’s case before the death of the B.C. child last May. And until Courtney died, only senior oncologists at the Halifax hospital had heard of two other similar deaths from chemotherapy mistakes in 1989: a 5-year-old boy form Chicoutimi, Que., and an 8-year-old boy from Thunder Bay, Ont., or of other similar deaths that had occurred in the United States.

Courtney was discharged later that day in April 1992. “She came downstairs irritable, vomiting, very drowsy, she drifted in and out of sleep. At 6 o’clock we left for home. I made her as comfortable as possible in the backseat and held her most of the way,” Donnalee wrote in her diary after the family finished the three-hour drive from the hospital home to Yarmouth.

Courtney had been home for only a few hours when her mom noticed she was not reacting to her chemotherapy as usual. The little girl spent a fitful night sleeping with her parents. In the morning her neck was increasingly stiff and she began to vomit. By that night she was screaming in pain; Yarmouth hospital admitted her with suspected meningitis.

“Courtney has deteriorated overnight–seems lifeless and just moaning,” wrote Donnalee in her diary the next morning. “I started to be really concerned and scared.” Courtney was flown by air ambulance to the children’s hospital in Halifax where doctors retraced her treatment and, to their horror, realized that the intravenous drug vincristine had been injected into her spine.

A week later, on April 30, doctors determined Courtney was brain-dead. They unhooked her form life-support machines. Donnalee’s diary detailed Courtney’s last moments: “They made a bed for Bob and me to cuddle Courtney… It would be the last time we would hold her. She started to turn blue and her heart slowly stopped and she was completely gone, gone forever.” Later, Donnalee insisted on an autopsy. No cancer cells were found in the little girl’s body; the child had been cured of her leukemia.

There are striking parallels between Courtney Braund’s death and the death of the child in Vancouver. Both children were treated outside the regular oncology units of each hospital. Where they were treated, hospital staff did not know about the safety procedures used for chemotherapy. In both cases, the two kinds of drugs–those to be injected intravenously and those to be injected into the spine–were delivered together. In Vancouver, the doctor checked the syringes as they were delivered in a clear plastic bag, but failed to notice one syringe hidden under three others; the Halifax doctor did read the vincristine syringe label, but he was preoccupied with another case and it didn’t register. And not all doctors at both hospitals were aware it had happened before.

How can hospitals be made aware of previous deaths, and the results and recommendations from inquiries? The coroner who investigated the death in Vancouver advised that a report on the case be sent to oncology centres throughout Canada and written up in medical journals. But that’s still no guarantee that the findings will be read, and the question still stumps medical experts. “You’d think hospitals would respond to news of tragedies in other places,” muses Dr. Chris Soder, head of the intensive care unit in Halifax and the doctor who led the investigations into Courtney Braund’s death. “But for us, like all human beings, there’s an assumption, ‘It can’t happen here.”

Dr. Charles J. Wright, head of evaluation and clinical epidemiology at the Vancouver Hospital & Health Sciences Centre, says hospitals can do much better at improving patient safety. He points out that even the top teaching hospitals in Canada have only in recent years adopted risk-management measures that are standard in many other industries. And even as risk management slowly makes its way into health care, says Dr. Wright, “It seems that each hospital has to reinvent the wheel.”

Experience, unfortunately, shows that mistakes can happen anywhere. When they occur in medicine, our instinct to point angry fingers of blame may actually work against the reduction of mistakes, by making those involved reduction to report even near accidents. Such reporting does happen in other industries, most notably in aviation: airlines are now required to report all near misses and mistakes–anonymously–to a central reporting agency that then distributes, throughout the industry, a description of the incident as well as potential solutions to problems. In the United States, the medical association’s Patient Safety Foundation is setting up a comparable national American reporting agency for medical mistakes. One result may be a trickle-down effect in Canada-for instance, by exerting pressure to make labels on drug packaging less similar and so less easy to confuse, or looking into the feasibility of designing new equipment solely for use in injecting drugs into the spine (as recommended by the Vancouver coroner).

Doctors involved in both the Vancouver and Halifax cases say a Canadian reporting agency would help. But in a time of scarce health care dollars and fewer rather than more regulations in all areas, there appears to be little likelihood that federal or provincial health ministries will act to put such an agency in place.

“When this happened in Vancouver, I couldn’t believe it,” says Donnalee Braund. And while she doesn’t think the same mistake will happen in Halifax or Vancouver again, she worries about other mistakes, other hospitals. Because even after the deaths of several children, not much has changed.

Copyright Deborah Jones 1998

 

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