I’m a doctor who made mistakes when treating patients – here are my golden rules to protect you

Can you imagine the distress of going to the hospital for an operation and having to return to the operating room to have the forceps removed because they were left in your abdomen?

Or go for surgery on your left hip because of years of excruciating pain and wake up to find they’ve operated on your healthy hip. Or surgery to save your ovaries – but they are accidentally removed. Or, worst of all, when you realize you had a procedure meant for another patient.

Fantastic stories invented for a TV drama? Unfortunately not. These were just some of the horrific mishaps that took place in hospitals across England in just ten months. They appeared in a list of ‘never-events’ released by NHS England a few weeks ago.

Never events are the most serious of the major medical errors. They literally shouldn’t happen. But between April 2022 and January of this year there were 325 of these “never events” in England alone.

Some argue that it’s a relatively small number for an organization that has treated millions of people over that time. But many of the patients behind the statistics are faced with the disastrous consequences.

Can you imagine the agony of going to the hospital for an operation and having to return to the operating room to have the forceps removed because they were left in your abdomen, writes Professor Rob Galloway

These stories do little to inspire the public to place their trust in medical professionals.

So why am I telling you this? Well, because behind the tragedies there are important lessons for all healthcare professionals – and also for those receiving medical treatment.

These patients have clearly failed; but pointing the finger at individual doctors or nurses is not the answer. Apart from isolated cases of people who should be incarcerated, health workers are absent from work and are intentionally causing harm.

And simply blaming and scapegoating will not solve the problem; it will instead cause employees to hide mistakes for fear of retribution. It will also prevent future patients from benefiting from the learning.

Nor is it true that the medical professionals themselves simply blame the pressure everyone is working under or the lack of resources, or say, “It’s just one of those things.”

These mistakes happen just as often in better funded hospitals abroad and in the private sector.

And it doesn’t just come at a huge personal cost to the patient: the NHS paid out £2.4billion in negligence claims in 2021/22 – and while the patient or their loved one understandably instinctively aspires to claim compensation, which they do the most common wish is to make sure this doesn’t happen to others.

Not only the patient is affected. A few years ago I was involved in a medical injury case from overprescribing fluids.

The patient ended up in intensive care and I felt guilty, depressed and on the verge of giving up the job.

Professor Rob Galloway, pictured, admits he has made mistakes when treating patients, writing: “I have come to realize that most mistakes are not due to a lack of care or knowledge, but to the fact that people are people.”

In fact, I have seen many colleagues suffer severe mental damage and quit their jobs due to medical errors.

So how can this happen in 2023? And most importantly, what can you do to protect yourself? To put it very simply, the reason for most errors is “human factors”: Modern medical care is incredibly complex and we humans are not designed for this complexity.

Understanding why medical errors happen has kept me busy for the last 22 years as a doctor: I teach courses and speak at conferences. So you might have thought that with my experience and obsession with the subject, I should make no mistakes. Unfortunately, this is not the case.

The more years I’ve worked as a doctor, the more I’ve come to realize that most mistakes aren’t due to a lack of care or knowledge, but because humans are humans and our brains are designed to hunt, run from woolly mammoths, and beget something more complex is difficult for us.

We don’t really multitask, we’re poor communicators, we assume we’re right, we don’t like when people challenge us, and we don’t notice things that may seem obvious from another angle or over time.

Basically, we are error-prone.

But we work in a culture that does not recognize “human factors” and therefore takes no steps to eliminate them.

Professor Galloway wrote: ‘A few years ago I was involved in a case where medical damage occurred because I was overprescribing fluids. The patient ended up in intensive care and I felt guilty, depressed and on the verge of giving up the job.

Years ago I cared for a seriously ill patient. I remember her because although we saved her life, my care could and should have been better.

I had asked for four units of “crossed blood” (blood of the same type as the patient).

Thirty minutes later I asked what happened to the blood and was told someone had told me their blood sample had been mislabeled. Because of this, no blood was sent from the lab.

But I hadn’t heard that news. I was too fixated and concerned about other aspects of the care she was receiving. So? I ordered new blood and it arrived 30 minutes later.

However, the delays affected her blood pressure and kidneys – and she then needed a longer stay in intensive care.

It wasn’t because I didn’t care. i care It’s not because I’m lazy: I’m not. It’s not a lack of knowledge – I have a long list of letters behind my name. I made this mistake because I’m human.

The solution is simple. My colleague could have spoken like this to get my attention and make sure I was listening: “Rob, it’s important that you listen: I have an update.”

Then I would only have had to repeat the crucial information. This is common practice in high-risk industries like airlines. It’s even common practice in non-high-risk industries like Chinese takeaways. I have never received the wrong food because when I order it, it is repeated to me.

This is societal and accepted normal practice in takeaway settings. But that’s not always the case in healthcare.

Just last week I was asked by one of my interns to examine a patient with a bad infection and low blood pressure. I made a plan with a list of steps that included kidney function tests and an antibiotic drip. After I asked the intern to repeat the list to me, she got defensive and said she had listened. But I do this because in the past when I haven’t, treatment plans have not always been followed and the patient has suffered as a result.

One of the things we medical professionals need to do is use plain English and no medical jargon. It’s so easy to confuse hyperkalemia with hypokalemia, with tragic results; less easy to confuse high and low potassium.

Another important way to improve patient safety is to ensure that following standardized working practices is the norm.

I introduced “prompt cards” for my team to treat time-sensitive conditions like sepsis with step-by-step reminders. These are based on Wetherspoons cocktail recipe cards and have helped transform the care we give and reduce errors.

But what can you as a patient do to protect yourself? If you tell someone you are allergic to something, have them repeat it.

If you are injected with any medicine, ask what you will be given.

If you need to have surgery, make sure you see the consent form and speak to the surgeon performing the surgery. Ask: “What did I do today” – always making sure that the surgical arrow is drawn on the correct side of the body and in the correct area.

Crucially, if you think something is going wrong, speak up. Remember: you are the last line of defense. Don’t let the medical staff intimidate you. Help us to help you.

As physicians, our Hippocratic Oath tells us that we must do everything possible not to harm patients. But as humans, we tend to make mistakes, and we must do what we can to reduce the likelihood of them happening. And that means really listening – patients and staff.

And every day I remember the mantra: “Don’t trust me – I’m a doctor.”

• Professor Rob Galloway works as an A&E consultant. Twitter: @drrobgalloway