We can and should minimise medical errors

Medical errors could be the biggest killer in Bhutan after noncommunicable diseases like stroke, cancer, chronic respiratory, and alcohol-related diseases. Sadly, however, medical errors and their causes are least studied and understood in the country due to lack of data, inexperienced staff, inadequate skills, influences of traditional beliefs and practices.

Recently, Bhutan Medical and Health Council reprimanded three doctors and nurses and withheld their certificate of good standing for a period of two years for negligence of duty. That was after the death of Bali Man Rana, 35, from Dagana at the Jigme Dorji Wangchuck National Referral Hospital (JDWNRH) in Thimphu following a surgery and the patient’s family lodged a complaint of negligence by health professionals.

And, between July 23 and August 9 this year, 11 babies died at the neonatal intensive care unit at the JDWNRH. Many such incidences have, of course, gone unreported.

What is medical error? Simply put, a medical error is a preventable adverse effect of care, whether or not it is evident or harmful to the patient. This includes an inaccurate or incomplete diagnosis or treatment of a disease, injury, syndrome, behaviour, infection, or other ailment.

In Bhutan, the problems that give rise to medical errors seem to be inadequate staff, lack of experience, training and skills and identical names of patients, among others. This is according to working health professionals. The main, however, problem has its root in the lack of study and date, which could otherwise help us determine and influence our actions to minimise deaths due to preventable errors. Informed consent between patient and doctors is a major problem in our health system today.

If medicine labels are hard to understand, there is a problem. If the doctors do not know about an individual’s medication and treatment history, there is a problem. Simple questions like what is the medicine for; how is one supposed to take it and for how long; what side effects are likely; is the medicine safe to take with other medicines or dietary supplements, and what food, drink, or activities should one avoid while taking this medicine could go a long way in preventing unnecessary, complicated and often dangerous medical errors.

Lack of experience, training and skills are a problem, of course, but they should not be an excuse for providing less than desired health services to the people. Studies and date gathering may be expensive, but it could save thousands of lives now and in the future. Free health services ought not to mean we can afford to be careless and unprofessional. There is a need to grow and excel.    

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