Murphy's Law and medical errors

Are you familiar with Murphy's Law?' asks Dr Poon Tak-lun, strolling out of Queen Mary Hospital after another day on the orthopaedics ward.

It's an odd way to explain the seemingly endless string of serious mistakes which have dogged Hong Kong hospitals, and Mr Murphy has yet to feature in any Hospital Authority press release.

There have been accidental injections of lethal drugs, doctors who snip out a fallopian tube instead of an appendix, nurses who inject milk and air into veins, pure chloroform dropped into baby syrup . . . the list seems endless.

But the Irish sage - or wag - may well have a role in pointing out why apparently well-trained medical staff suddenly inject a lethal drug into an elderly man and a baby boy, or why doctors operate on a teenager's left eye instead of his right.

Dr Poon, the Public Doctors' Association chairman, may have a point: what can go wrong will go wrong. 'When you look at all these things, you'll find that each of them has predisposing causes,' says Dr Poon.

The three known cases of accidental injection of potassium chloride - one last August, another in June and a third earlier this month - illustrated what needs to be done, he says.

'This is a very dangerous drug if injected in concentrated form. It has just a small sentence on the bottle, which is also small, telling people to dilute it. It would be very easy to miss the small print on the bottle.

'If the potassium chloride was not dispensed in this form, but as a crystal solid, there would be no way you could administer it in concentrated form. You would have to dilute it. You'd have the same convenience, but the chance of accidental administration is much reduced.' Simple, but effective. If a dangerous drug cannot physically be injected, chances are it won't be.

Dr Poon and Mr Murphy have made their point.

'The procedures are not designed in a way to prevent mistakes. To err is in human nature, but we can be active participants to prevent mistakes.' The Hospital Authority itself often seems baffled over how to stem the image-battering series of blunders which have stained its record.

'It's a very difficult question,' says the authority's deputy director of operations Dr Ko Wing-man.

'Medicine is not an exact science. I'm not saying I can offer a perfect answer. The responsibility of health-care workers is to try to build up the expertise, the confidence and the system supports, so that human errors will not affect the patients.' The authority has put much research into creating guidelines - such as the ubiquitous 'three checks' which calls for nurses to check medication at three stages before administering it - to catch mistakes before they affect patients, he says.

In cases where drugs had been stored in wards in a 'very haphazard manner', they were now carefully stocked in trays and locked cupboards.

'And the trolleys - before you just dumped all the patients' drugs into the trolley. Now we have individual drawers for each patient,' says Dr Ko. 'The likelihood of making a mistake is less.' Likewise, computerised patient records should make it easy for staff to check whether a patient can be prescribed certain drugs, or undergo special treatments.

Still, the Hospital Authority's Medication Incidents Reporting Programme, set up in 1995 to keep track of 'incidents' - Dr Ko declines to refer to them as 'mistakes' - shows alarming figures. Until the end of 1996, about 5,000 incidents were being logged every three months. Throughout 1997, the number grew to 6,046 in the third quarter.

It also points out, in one report: 'Since error rates depend mainly on voluntary reporting, a high reported error rate may just mean diligence in reporting.

In most cases, mistakes involve drugs given to patients - either doling out the wrong strength, mislabelling or, predominantly, simply dispensing the wrong drug.

The authority's internal report also looks at the causes of incidents.

The overwhelming majority - 33 to 41 per cent last year - were put down to simply 'distraction' or 'stress'. The second most frequent reason is 'performance deficit'.

Checks and guidelines ensure most incidents are caught before they can affect the patient, says Dr Ko.

Medical Association chairman Dr So Kai-ming called for better training to keep pace with leaps in medical practice and knowledge.

'We're dealing with a changing medical scene,' he points out.

'Many years ago, the treatments were simpler and there were fewer. Nowadays, you have more choices of treatment and they are more complicated. There are more opportunities for mistakes to be made.

'I think training is important because treatment, these days, is more complicated. In the 1940s and 1950s, you'd go to a doctor, he gives you the medicine and nothing more is done - you're either cured or you're not.' From doctors and nurses, hospital staff have expanded to include physiotherapists, occupational therapists and a plethora of doctors and nurses in new specialties. 'If anyone in that team makes a mistake, there will be consequences,' says Dr So.

'The strength of any chain depends on its weakest link. If anyone makes a mistake, the whole thing breaks down.' Watching the string of medical mistakes unravel, from the cloistered halls of the University of Hong Kong, are 866 medical students. These are Hong Kong's future; their hands will heal the next generation of SAR citizens.

Dean of Medicine Professor Grace Tan Wai-king is concerned about the incidents, and discusses them regularly with her students.

'Nowadays we talk about it,' Professor Tan says. 'We try, in our new curriculum, to bring it into discussion. From day one, we really try to make them recognise what counts.' The answer, Professor Tan says, is to drum into students - and practising staff - a sense of the importance of their jobs. That their actions can constitute life or death for innocent people.

'All medical practitioners - doctors, nurses, anybody dealing with the health of the sick - should realise what they're doing and be extremely, extremely careful. That should always be borne in mind,' she says.

'We can always drill people, examine them and test them, but at a particular moment when we're doing something routine, day in and day out, the element of care must be there.

'We have to be cautious in what we do - and put our hearts into it. Medical and nursing training is not easy, and the sort of people who are committed and go through it are not those who work without a heart.'