extracted from stforum.
Health care system must stop blaming individuals. Set up fail-safe
methods instead
I refer to the report 'Nurse found negligent but coroner praises
her' (ST January 1
. It is most commendable for the State Coroner, Mr Tan
Boon Heng, to give due recognition to the challenging circumstances
under which the nurse, Mdm Grace Leong, had to care for 180
patients singlehandedly in the Tembusu Home.
Learn lesson from sad story of drug allergy death. Give those who
erred a chance.
However, it is most unfortunate that Mdm Leong was found negligent
when in fact the error that she made was non-intentional and a
completely human one.
What can we expect of a nurse called to perform super human duty?
It is very sad that there is no recognition of the selfless and
professional caring given by Mdm Leong to the residents as
evidenced by the comments from the daughter of the deceased, that
the latter 'was asthmatic and had health problems due to his long
stint of drinking... but he was doing fine there.'
I also fail to understand the rationale to strike Mdm Leong off the
roll as a nurse when Ms Susie Kong, executive director of the
Singapore Nurses Association, had stated, 'How can you expect a
nurse who has to take care of all 180 residents to also provide the
standard of care that is expected to be given to sick
patients?'
Furthermore, should not the responsibility of the error be shared
by the hospital that had made the diagnosis of allergy? Why was not
the patient registered with Medik Awas and given a bracelet to be
worn at all times?
An article in the Singapore Medical Journal in 2002 has recommended
that a systems approach be adopted towards improving patient
safety. To quote: 'The systems approach makes the fundamental
assumption that health care related or medical errors are, with
rare exception, not caused by incompetent or uncaring physicians,
nurses or pharmacists. People make mistakes no matter how hard they
try.
"Analyses of errors clearly reveal that underlying vulnerabilities
in the system are the primary problem. This means that the health
care system must cease blaming individuals and design checks and
balances ('fail-safes') into care and delivery processes to catch
and correct errors before a patient is harmed.'
It has also been noted that 'we have an intense blame culture to
grapple with, and this constitutes the greatest hurdle in
developing our hospitals into high reliability
organisations.'
We need to become a more humane society and to learn not to judge
others without first coming to terms with our own human weaknesses
and failings. It is a sad day for our nation when a caring nurse is
penalised for making a purely human mistake in performing a
superhuman duty!
Dr Patrick Kee Chin Wah
