Medical mistakes

Here’s another question of an order of magnitude… Daniel Ubani, a German ‘stand-in doctor’ who was over in the UK doing a shift as an on-call GP and gave a patient a fatal overdose of diamorphine (Guardian again). He gave the patient 10 times the amount – at first I wondered if he’d got millilitres and centilitres mixed up. However, you can now read the inquest material and it makes for interesting reading.

It seems that the mistake came when David Gray’s partner mentioned 100mg and 10mg, pethidine and diamorphine, in the same conversation. Having no pethidine, Ubani chose the diamorphine. Hearing 100mg, he chose the bigger vial. As diamorphine isn’t used in Germany he wouldn’t know the correct dose: he didn’t look at the instructions kept with the drugs, hence ‘manslaughter by gross negligence’. However, the death could have been prevented by proper induction. It seems that no-one showed Ubani round his equipment: he should have known that the 100mg vial was for palliative care and used in slow release with a syringe driver, as opposed to all at once.

At the inquest there was a some discussion about Ubani’s proficiency in understanding English. However, one of his employers said that his English was OK, and it seems unlikely that this was a huge factor. His unfamiliarity with NHS kit and procedures was more to blame. However, the papers seem to have decided that the black African with a German passport was an example of non-English speaking foreigners making a mess of things (see the Mirror). There’s a lot of blame on the profit making agencies too.

But, as noted in the report, this has happened before, and the month before the deaths NHS Cambridgeshire were discussing changing the boxes of drugs to avoid this:

“In attempting to relieve patients in acute pain, doctors in two different situations erroneously selected the 30mg diamorphine vial…and administrated the entire contents to their patients by injection.

“This six-fold overdose caused respiratory depression and collapse; the patients had to be admitted to hospital for resuscitation. If this is repeated and the patient not rescued in time, death could result.” (C4)

I don’t know if these doctors were the stereotyped foreign doctor, unable to speak English, or not. The lack of media interest suggests not as I’m sure a scandal would be being promoted as I write.

Indeed, focusing on this rare occurence misses the wider issues in ‘patient safety’. If society is fixated on this one fatal mistake, then it can ignore the fact that in 2007 there were ‘as many as 860,000 errors or near misses involving medicines’ in the NHS (Guardian). I’m sure that not all these mistakes were down to foreign doctors, but are down to normal human error, the kind of error that can often be avoided with the right systems in place, good management and so on. Dull (and expensive but that’s another story).

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Filed under bad social science, media, News, Statistics and simplicity

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