How to proceed with Nashwa’s case?

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A nine-month old girl died after battling brain paralysis which resulted due to a drug overdose at a hospital in the city of Karachi, Pakistan. Unfortunately, hundreds – if not thousands – die untimely every month due to medical negligence in hospitals worldwide. Sometimes the carelessness come out openly as it did in the case from Darul Sehat Hospital. Other times it remains obscure under the reassuring testimonials such as ‘there were complications’‘patient was unfortunate’‘doctors tried their best’ etc.

Before dissecting the issue further, let’s get one thing clear. All those involved in this laxity did not intend the consequences their actions brought. No one wanted Nashwa Ali to die. However, their neglect did cost an innocent girl avoidable suffering whose cost was paid with her own life and a lasting grief to her family.

Seen in retrospect, their neglect was a set of failures. Failure to follow the procedures, failure of ensuring the appositeness of the injection, failure of supervising the treatment, failure of not paying the due attention, failure of administering the amount of dosage.

To err is human. We humans have been failing in our endeavours since the recorded history. Whether it be the medical profession or any other walk of life, failure is almost unavoidable. However, how we deal with failure is imperative. Every failure is an opportunity to learn and improve the situation so, at least, the same misstep can be stopped from repeating. To do so, it requires: an open acceptance of the mistake, staunch willingness to learn from it, and – building on the learning – a changed behaviour to not let the same mistake repeat.

Take commercial aviation for example. Every day hundreds and thousands of flights take off and land safely. Over the decades the number of incidents and accidents in aviation have diminished significantly. Fatalities have never been any lower in the history of aviation, with 2017 being the safest year in history for commercial airlines. As per the industry research, there were no passenger jets crashes anywhere in the world in that year. Flying is the safest mode of transport today. It is partly due to the advancements in technology, better training and management under the so called the Crew Resource Management, and improved safety measures in place. But flying was not always as safe as it is today. A fair share of the gains goes to the systematic approach put in place firstly in the USA and in the wider world later, in response to the high number of air plane incidents in 1920s. Among other steps, the approach comprised of a decisive resolution of reporting any incidents however small they may be, impartially investigating them, and sharing every bit of the probe so that everyone can learn from what can possibly go wrong and how it can be avoided. Today, even the tiniest of the events get reported, investigated and the learning get shared with almost every pilot and the wider aviation community. Be it be a fatal crash or a near-miss, the mantra is to record it, analyse it and share the learning so the likelihood of it happening again is statistically reduced to zero. The pilots are incentivised to speak-up by ensuring them confidentiality and immunity if they voluntarily report their or their peers’ mistakes within an agreed time-frame of the incident.   

Health sector, in contract, has a different approach when it comes to errors. Almost none anywhere get acknowledged, let alone recorded and investigated. The inflexibility to record the mistakes in the health sector is fathomable. Firstly, those making the misdeed are never the victims, unlike pilots whose mistakes cost them their lives too. While often the mistakes of pilots – if that be the case – are voiced by the black-boxes (which are now orange in colour to assist their spotting), doctors and nurses have to acknowledge their own mistakes which in itself is a weighty ask. Psychologically, we are wired such that it is hard for us to accept our mistakes. Secondly, the higher up we go on the seniority ladder, the more unyielding our egos become. Thus, tougher it gets to admit that we too could be wrong.

No one is doubting the intentions of the health practitioners. They are doing noblest of the noble jobs. Without them, world would be an abysmal place. What I am humbly articulating here is how they respond to their own errors and failures. We need to understand that we all – including doctors and nurses – are humans, susceptible to mistakes. All the progress this world has made stands on the shoulders of earlier failures. Errors, after all, are important. They show us our shortcomings and provide us prospects of learning and growing. The moment we will change our approach towards failure, real change will set in action.

To improve health-care in response to human errors, I recommend every parish to maintain what I call a ‘Learning’s Journal’ which would in good conscience record every mistake or incident taking place at health facilities in its dominion. The doctors and nursing staff would be encouraged to voluntarily report the incidents in exchange for immunity and anonymity. A dedicated team of experts would inspect, analyse and report back on the incidents so that the same errors do not repeat anywhere. The Learning’s Journal database would be available to the wider medical practitioners and students so everyone else can learn from the mistakes of their peers.

Because mistakes in health sector have such hefty costs, it is all the reasons to accept them, log them, analyse them and learn from them. Why should not we all resolve to adopt the same systemic approach – to our personal and societal – mistakes so at least not the same mistakes gets repeated? We have seen the results of this approaching saving thousands of lives in the aviation industry. Why not medical field adopt it too? Because failing in something once offers an opportunity but failing on the same twice becomes a choice. Nashwa is not coming back. But how we respond to the failures that costed Nashwa her life can ensure that no other girl meets the same fate she and her family did.

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