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EVIDENCE-BASED-HEALTH  February 2018

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Subject:

Re: Off-topic? Dr Hadiza Bawa-Garba, a patient-safety cultura no EBM

From:

Rinku Sengupta <[log in to unmask]>

Reply-To:

Rinku Sengupta <[log in to unmask]>

Date:

Tue, 6 Feb 2018 07:01:20 +0000

Content-Type:

text/plain

Parts/Attachments:

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text/plain (598 lines)

Not called- not informed. Cant help - sorry - they say.
http://www.bailii.org/cgi-bin/format.cgi?doc=%2Few%2Fcases%2FEWCA%2FCrim%2F2016%2F1841.html&query

Rinku Sengupta

--------------------------------------------
On Mon, 5/2/18, joseph ana <[log in to unmask]> wrote:

 Subject: Re: Off-topic? Dr Hadiza Bawa-Garba, a patient-safety cultura no EBM
 To: [log in to unmask]
 Date: Monday, 5 February, 2018, 22:49
 
 What is happening to
 our good old and cherished NHS UK?  I still think that for
 every bad situation there are loads of good ones that many
 of us know of and can attest to. But Juan is right, system
 failure happens before individual ones follow in most cases.
 Disappointed not to read about what happened to the managers
 who let the resident work in such horrendous conditions. Are
 the system and managers let off ?  What happened to
 them?
 Joseph
 Ana.
 Africa Center for
 Clin Gov Research & Patient Safety
 @
 HRI West Africa Group - HRI WAConsultants in Clinical
 Governance ImplementationPublisher: Health and Medical
 Journals 8 Amaku Street Housing Estate,
 Calabar
 Cross
 River State, Nigeria
 Phone No. +234 (0) 8063600642Visit Website: www.hriwestafrica.com
 E-mail:
 [log in to unmask]
             
 
 
             
             
                 
                     
                     
                         On Monday, 5 February 2018, 20:45:52
 GMT, Michael Power <[log in to unmask]> wrote:
                     
                     
 
                     
 
                     There was a
 good reason that “respondeat
 superior” became a legal principle.
 There is an
 ungood reason that "respondeat superior” is evaded by
 employers.
 Michael
 
 On 5 Feb 2018,
 at 18:56, Juan Gérvas <[log in to unmask]>
 wrote:
 -my comment
 about this case which is chilling health professionals
 around de world
 -in
 Spanish: http://www.actasanitaria.com/e
 rror-medico-mortal-que-convier
 te-a-una-residente-de-pediatri a-en-criminal/
 -copy
 bellow and attached
 -of
 course, i am a Spaniard so sorry for my English and my
 (probably) mis-understanding of the process
 Deadly
 medical error that turns a Pediatric resident into a
 criminal
 
 Juan
 Gérvas, retired rural general practitioner, CESCA Team,
 Madrid,
 Spain
 [log in to unmask]
 www.equipocesca.org
 @JuanGrvas
 
 Case
 report
 Friday,
 February 18, 2011,
 children's emergencies at the University Hospital of
 Leicester,
 United Kingdom.
 At 10.30 the
 pediatric resident ("register")
 in charge of the children's emergencies, and of the
 entire children's
 hospital, including hospital beds and the ICU, as the
 "consultants"
 were not present and the two companions of at the same level
 they had
 permission, valued a six-year-old male referred by his
 general
 practitioner (family doctor), with poor general condition,
 diarrhea,
 vomiting and dyspnea. The patient had a history of cardiac
 surgery,
 was under treatment with enalapril and had Down syndrome.
 With the
 initial diagnosis of gastroenteritis shock, the resident
 ordered
 parenteral rehydration and support oxygen. Thinking of
 pneumonia, he
 asked for a chest x-ray and a blood test, including
 gasometry.
 The
 resident had a younger resident and a student and, after
 this case,
 she worked without rest attending other urgent patients. In
 addition,
 the electronic system worked badly and had to call by
 telephone to
 receive the results of analysis and other tests.
 At 15.00 h.
 the
 resident examined the child's X-ray. Such a chest x-ray
 had been
 received at 12:30 but the resident had not been notified,
 despite the
 fact that showed the presence of pneumonia. Therefore
 prescribed
 antibiotics, which were administered at 16.00 h. The
 resident
 received no information about the oxygen being withdrawn
 neither
 about the fever affecting the patient. 
 
 At
 16.15
 h. the resident received the tests that had arrived at 10.44
 h, with
 renal alterations, a high CRP, pH of 7 and lactate of 11.
 Subsequent
 analyzes showed the normalization of pH.
 At 16:30 the
 resident met
 her chief "consultant" in the corridor and told
 her the
 case and the analytical results, without requiring further
 help. At
 18.30 pm he commented again.
 At 7:00 p.m.,
 the patient went to
 hospital beds and the mother gave him enalapril. The
 resident
 had
 clearly recommended not administering it.
 At 20.00 there
 was an
 emergency call to take care of the patient, due to cardiac
 arrest.
 The resident went immediately and confused the patient with
 another
 in which there was order not to do cardiopulmonary
 resuscitation, so
 he suspended this activity for a few seconds until he was
 warned of
 the error and reanimation resumed.
 At 21:20 the
 patient died (due
 to septicemia and cardiogenic
 shock).http://thehealthcareblog.com/b
 log/2018/01/30/to-err-is-homic ide-in-britain-the-case-of-dr-
 hadiza-bawa-garba/
 
 http://www.54000doctors.org/bl
 ogs/whos-interests-are-the-gmc
 -really-trying-to-serve-in-the
 -bawa-garba-case.html?
 
 
 
 Dr.
 Hadiza Bawa-Garba, the resident of
 pediatrics
 The
 resident of pediatrics is Nigerian, Muslim with hijab and
 black. It
 had an excellent curriculum. She was tanned in almost all
 areas of
 pediatrics since it was her sixth year of residence. In
 fact, its
 "register" name alluded to its professional
 situation of
 great responsibility in which it is expected that she
 dominates
 uncertainty and makes sound decisions without having to
 bother the
 "consultant", who is usually located but rarely
 intervenes.
 The resident
 of pediatrics had been thirteen months of
 maternity leave and had just joined the university hospital
 in
 Leicester, which she did not know and of which they did not
 make a
 presentation.
 
 The
 penalty
 The
 first review exempted the resident who continued working in
 the
 hospital. The second review, in court, four years later, in
 November
 2015, sentenced her to two years in prison and one year
 without
 professional practice for "homicide due to gross
 negligence"
 (the sentence to the nurse, Portuguese, was similar but in
 both cases
 did not require entry into
 prison)
 http://www.pulsetoday.co.uk/yo
 ur-practice/regulation/gmc/baw
 a-garba-timeline-of-a-case-tha
 t-has-rocked-medicine/20036044 .article
 The
 resident challenged the ruling and the GMC court reaffirmed
 the
 ruling in June 2017 (the General Medical Council, GMC, is
 responsible
 for registre doctors and defending patients against their
 mistakes
 and excesses).
 However, the
 board of directors of the GMC
 considered that the punishment was insufficient and, against
 the
 decision of its own court, took the case to the Supreme
 Court (High
 Court) that agreed with the suggestion of the board of
 directors to
 remove the license from doctor so she could never again work
 as a
 physician, as Dr. Hadiza
 Bawa-Garba
 http://blogs.bmj.com/bmj/2018/
 01/30/charlie-massey-we-are-co
 mmitted-to-making-health-servi ces-a-place-for-learning-not-
 blaming/
 
 
 http://www.dailymail.co.uk/new
 s/article-5310161/Ruling-docto
 r-convicted-boy-s-death-struck -off.html
 
 The sentence
 came out on January 25, 2018 and caused an
 earthquake in the National Health Service of the United
 Kingdom.
 Thousands of doctors signed a letter against the sentence,
 warning of
 the dangerous precedent against the safety of the patient
 because the
 judgments and legal punishments focus on the professionals
 not on the
 problems of the
 system
 http://researchonline.lshtm.ac
 .uk/3172373/1/Shadow%20of%20th e%20law_GOLD%20VoR.pdf
 
 http://www.54000doctors.org/bl
 ogs/whos-interests-are-the-gmc
 -really-trying-to-serve-in-the -bawa-garba-case.html?
 
 
 http://shibleyrahman.com/nhs/t
 he-perfect-storm-around-gawaba
 rba-was-a-long-time-coming/
 
 In 24 hours
 the doctors collected 230,000 euros to continue the
 judicial process and pay a new defense to Dr. Hadiza
 Bawa-Garba.
 "As
 doctors, we know that any of us could be the next Dr. Hadiza
 Bawa-Garba" and at the time they remembered that 30% of
 the
 doctors are from non-white ethnic groups, which is not
 reflected in
 the leadership of the
 GMC
 http://www.independent.co.uk/v
 oices/hadiza-bawagarba-british
 -doctor-jack-adcock-manslaught er-gmc-nhs-crisis-latest-
 a8189096.html
 
 
 
 The
 system holes
 In the study
 of medical
 errors, a distinction is made between systematic problems
 and
 personal problems. The key is to study the errors avoiding
 burdening
 the faults on the doctors because many times they are only
 part of a
 chain of failures, of systematic "holes" that make
 possible
 the error with damage when there are personal problems. It
 is the
 model developed by Dante Orlandella and James T. Reason
 (University
 of Manchester) in 1990 and later revised in 1995 and 1997.
 This model
 establishes that the emergence of a failure or error and its
 consequences, in terms of losses and damages, it owes to
 certain
 fragility conditions -active or latent- inherent in the
 systems,
 which are capable of altering their capacity to defend
 themselves
 against error. This model uses the metaphor of the slices of
 Swiss
 cheese, equating the substance, the cheese, with the
 defenses or
 barriers that contain a system to avoid that errors occur,
 and the
 holes with the conditions of vulnerability. In their
 approach, the
 authors state that when the slices are aligned, so that
 several holes
 -or conditions of fragility- coincide, it is when the error
 occurs.
 The task, of course, is to reduce these conditions and
 prevent them
 from aligning
 http://www.bmj.com/content/320
 /7237/768
 
 "When a
 patient suffers a damage or adverse event, there is
 the so-called retrospective bias: everyone looks to see what
 happened
 and only see the doctor or nurse who attended him, do not
 see other
 factors that intervened so that the adverse event could
 occur.
 The
 bias is like looking through a hole that only allows them to
 see the
 professional who treated the patient. You can not see the
 working
 conditions, the human and material resources, the
 organization,... In
 order for an adverse event to occur, all the defenses or
 barriers
 that should have prevented it, both human and system, must
 fail. The
 first barrier or defense of the system is the organizational
 one, the
 second the supervision, the third the unsafe conditions and
 the
 fourth the unsafe acts. The safe systems minimize the risk
 of damage
 even if there are failures in some of the defenses, since
 the others
 prevent it
 "
 http://sano-y-salvo.blogspot.c
 om.es/2015/03/practicas-segura
 s-en-sistemas-seguros.html
 
 
 
 Unsafe
 system
 In the case of
 Dr. Hadiza
 Bawa-Garba, the cheese was more than bored. For pointing out
 some
 holes:
 1. The
 resident returned to work after a long maternity
 leave that would have required a "soft
 landing".
 2.
 Nobody explained to the resident how the hospital worked,
 nor how
 best to solve the specific problems during her duty.
 3. On the day
 of the events, the resident was alone because the other two
 residents
 of the same category, "register", were missing
 from
 work.
 4. The
 category of "register" is relatively new
 and allows to load on residents with experience a clinical
 weight
 that facilitates savings in fees to
 "consultants".
 5. On
 the morning of the incident the head of the resident, the
 "consultant" was teaching in another city.
 6. The
 "distance to authority" is enormous in the United
 Kingdom,
 so that the figure of the "consultant" was not
 real help
 for the resident.
 7. The work
 overload of the resident is
 documented on the day of the event.
 8. The nurses,
 also
 overburdened, did not identify the progressive deterioration
 of the
 patient.
 9. The
 resident was involved in special urgent cases that
 required her direct skills such as lumbar punctures, not
 delegable to
 other professionals present.
 10. The
 computer system did not work
 so that the results had to be received and claimed by
 telephone,
 directly.
 11. The x-ray
 was not reported because there was no
 staff for it.
 12. The
 information flows were deficient as seen
 with respect to the delivery of the evidence to the
 resident.
 13.
 The orders were met late as it was seen in the interval of
 one hour
 between prescribing antibiotic treatment and administering
 them.
 14.
 Caregivers often establish a safety curtain but in this case
 the
 mother administered the enalapril that probably precipitated
 the
 final aggravation.
 15. The
 mistake of confusing the patient and
 stopping cardiopulmonary resuscitation was the end result of
 hours of
 work without rest, excessive responsibilities and poor diet
 and
 hydration.
 
 SynthesisA
 single trainee was held accountable when there were so many
 systemic
 errors in this case. We have a first victim, we cannot
 change his
 death, but we can avoid cruelty with the second victim of
 the error,
 the mother and Dr. Hadiza Bawa-Garba. Task errors by
 emergency
 physicians are associated with interruptions, multitasking,
 fatigue
 and working memory capacity. We can profit the opportunity
 and
 improve the system to avoid the same error
 (integrating
 second victims' experiences into safety culture and
 root-cause
 analyses). 
 http://qualitysafety.bmj.com/c
 ontent/early/2018/01/19/bmjqs-
 2017-007333?rss=1&ssource=mfr&
 hootPostID=c216ec1e148463f7be5 f83c0d1dce8a8
  
 https://journals.lww.com/journ
 alpatientsafety/Abstract/publi
 shahead/A_Transactional__Secon d_Victim__Model_Experiences.
 99393.aspx
 
 It is the
 medical obligation to identify the errors and their
 consequences. After identifying them you have to explain
 them, ask
 for forgiveness for the damage, repair it as much as
 possible and
 take measures to avoid its
 repetition.
 http://equipocesca.org/etica-d
 e-las-pequenas-cosas-en-medici na/
 
 Society has to
 accept that medical work entails errors and that
 such errors tend to have more to do with the system than
 with
 professionals.
 A culture of
 safety for patients is established,
 avoiding the generalized criminalization of doctors and
 stopping the
 damages in domino caused by second and third victims
 (professionals,
 caregivers, etc) without avoiding the repetition of damages
 to the
 first victims
 (patients)
 http://sano-y-salvo.blogspot.c
 om.es/2017/06/primeras-segunda s-terceras-cuartas.html
 
 http://www.bmj.com/content/359
 /bmj.j5534
 
 The #BawaGarba
 case demands a new culture in medical training so
 that residents are not forced to work in unsafe conditions,
 as
 recognized, for example, by the Royal College of Physicians
 of
 Ireland
 https://www.rcpi.ie/news/relea
 ses/royal-college-of-physician s-of-ireland-to-review-
 protocols-for-trainees-in- light-of-dr-bawa-garba-case/
 
 
 NOTES
 
 1.
 Who among us has not made mistakes with harm to patients?
 Http:
 //www.bmj.com/content/360/bmj.
 k485
 2. "Every
 surgeon [doctor]
 carries inside a small cemetery to which he will pray from
 time to
 time, a cemetery of bitterness and sorrow ..." R.
 Leriche. "La
 philosophie de la Chirurgie". Part II, chapter I.
 https://primumnonnocere-edita.
 blogspot.com.es/2017/07/leccio
 nes-de-un-maestro-rene-leriche .html
 
 3. "Bank
 of clinical cases of errors that hurt but they
 teach" #siapGranada Testimonies about painful events
 for
 patients, for their relatives and for the doctors who
 attended
 them.
 http://sano-y-salvo.blogspot.c
 om.es/2015/04/errores-que-duel en-pero-ensenan-20.html
 
 4. And if the
 circumstances are such that it is forced to work in
 conditions that go against the safety of professionals and
 patients
 the logical thing is to refuse to do so, stop working, make
 the
 corresponding urgent complaint in the Court and return to
 the post of
 work not to miss in presence [against what the GMC advises
 in the
 United Kingdom] http://www.bmj.com/content/360
 /bmj.k448
  https://gmcuk.wordpress.com/20
 18/ 02/02 /
 faqs-outcome-of-high-court-app eal-dr-bawa-garba-case /?
 Utm_campaign
 = 9132068_GMC% 20news% 20-% 20January% 20% 28resend% 29
 &
 utm_medium = email & utm_source = General% 20Medical%
 20Council &
 dm_i = OUY, 5FQCK, HWPYSM, L1VA5,1  
 5. United
 Kingdom. Doctor in
 the ICU. Call to warn that there is little staff and
 endanger the
 lives of patients? Think twice! The terrible case of Dr.
 Chris Day.
 http://www.dailymail.co.uk/new
 s/article-4503734/The-dedicate d-NHS-doctor-tried-gag-
 destroy.html
  
 
 
 
 
 
 
 
                 
             

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