Deadly Mistakes

It is expected that doctors will do their best to protect the well being of their patients. However, the health care system that they function in is a complex one where the possibility for them to make mistakes is abundant. Unlike other professions like in accounting, law, engineering and even education, where mistakes made need not necessary be fatal, often when doctors make mistakes, they are lethal. Two recently cases highlighted in the press support this hypothesis

Firstly, at the coroner’s inquest into the death of Madam Koh At Tow, 88, it was decided that a series of mistakes made at Clementi Polyclinic in March last year caused her death. The doctor had prescribed the wrong dose of heart medicine and was given four times the dose which was not picked up at the pharmacy.

Secondly, Mr. Tan Beng Kiat, 30, on June 21 had a severe headache. He was given painkiller by the general practitioner but the medication did not help. He was send to Tan Tock Seng Hospital where he was also diagnosed as having a headache. The attending doctor decided that there was no need to do a scan or have him hospitalized. He was send home with more painkillers. That evening he fell into coma and was pronounced brain dead by doctors at Singapore General Hospital. He was taken off live support and was pronounced dead later.

We seldom expect nor accept medical errors but they do account for some hospital injuries and deaths. To many, it is acceptable as long as it does not happen to us or our love ones. This is because medical mistake is avoidable and the adverse injury caused as a result is due to medical mismanagement and not due to the underlying medical condition of the patient.

While it is all too easy for society to blame the doctor and the concerned doctor in turn may become defensive and blame the nurse, the hospital, the work load and even the system for the mistake, we need to re-examine how doctors and society handle medical errors.

Is it true that good doctors never make mistake? Are doctors always right? At what stage of our medical conditions should we seek a second opinion? What do we do if what we are experiencing do not aligned with what the doctor is diagnosing? What do doctors do when they make medical mistakes? Do they hide them or worst bury them?

Do doctors share with their colleague, peers and junior doctors their adverse mistakes or are they afraid that if they do they would be inundated with malpractice suit?

An old adage extolled that a wise man learns from fools’ mistake. Do our doctors learn from each other mistake for the sake of the patients?

Perhaps it is time to move from a culture of blame and shame to a culture of share and care.

We have to share our experiences and mistakes so that processes, checks and balances can be put in places so that similar medical mistake can be reduced or eliminated.

For instance, in the first case, the National Healthcare Group (NHG) has introduced additional processes in the system so as to reduce the risk of patients getting a wrong dose of medicine. Now a senior doctor is required to countersign any changes in the dosage of some toxic medicine and an electronic prescription system will alert doctors to a patient’s drug allergies. The family of Madam Koh At Tow has decided not to pursue the matter with the doctor concerned as they did not wish to destroy the doctor’s career.

But how would society view her mistake? Would we bring ourselves to entrust her with our medical conditions? What about herself? Would she be able to re-gain or re-built her confidence? It would be a waste of resources, time and effort if she is unable to overcome this current event.

We should encourage doctors who made mistakes to learn from them and move on to continue their good works. After all they are human too.

However, if the doctors are found to be negligent or fail to show due diligent in their performance of duty, the full extent of the law should be weight down upon them and taken to task.

The difficult task is for us to discern the difference between these two.