In Bhutan, medical errors and their causes are least studied and understood due to lack of data, inexperienced staff, inadequate skills, influences of traditional beliefs and practices.

This issue was discussed at panel discussion at the pre-conference workshop of fourth International Conference on Medical and Health Sciences in Thimphu yesterday.

The panelists were from Jigme Dorji Wangchuck National Referral Hospital (JDWRNH), Bhutan Medical Health Council, and All India Institute of Medical Sciences.

Nursing Superintendent of JDWNRH, Tandin Pemo, said the most common medical error in the country was medication error caused because of unclear handwriting. “The nurses take instruction from doctors and make mistakes during the transcription because of not clear handwritten prescription,” she said.

Inadequate staff, lack of experience, training and skills and identical names of patients, among others, were the cause of the errors.

The hospital has put in place standard operating procedures, started to write the prescription in block letters and encouraged double-checking to avoid errors.

Tandin Pemo said that negligence and incompetence of health professionals were not only the reason that caused errors. “The causes of medical errors are numerous and have many components. Medical errors are a direct result of how the health system is organized and how care is delivered.”

According to the Institute of Medicine (IOM) report called To Err is Human 2000, about 98,000 unnecessary deaths occurred each year due to medical errors. The most recent study, conducted in 2013, suggested the numbers range from 210,000 to 440,000 deaths per year.

Tandin Pemo said that the there was no research and studies done about the number of deaths caused by medical errors in the country.

“We don’t know how many patients died and were harmed by errors. To my knowledge, there were few incidences where patients died after wrong medication and were disabled after wrong surgery. But we don’t have data,” said Tandin Pemo.

She added that the systems were in place to minimise errors.  “They are not enough to prevent all mistakes. Every error has a root cause and every cause has a solution. Errors can be prevented with everyone’s initiative in the system.”

The discussion highlighted guidelines, policies and SOPs put in place to study the situation and to reduce errors. The panel encouraged documentation of patient treatment, information, and communication among the health professional, which was found be wanting today.

Registrar general of Bhutan Medical Health Council, Sonam Dorji, said that it was difficult to say whether it was a medical error because of various factors that affected medication and treatment.

“We feel that a health professional lack skill of communication when a patient is more convinced by religious people and traditional beliefs. The patients come late for the treatment,” he said. “We are trying to make up health and religion programme to educate religious people not to delay patient’s treatment.”

He said that the demands for the health services have changed because of public awareness and education.

Dr Shakti Kumar Gupta from AIIMS said that it was difficult to treat patient today with the availability of information on the Internet and enhanced education level among the public.

Nima and Sonam Choden


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