TV: Uncomfortable viewing
Authors: C. Martyn
Journal: BMJ (2000)

Why doctors make mistakes Channel 4, Mondays at 9 pm, 2 to 17 October

Screw ups, slip ups, and cock ups; miscalculations, misjudgments, and misdiagnoses. That, I'm sorry to have to tell you, is this four part series's, appraisal of our professional performance. 

Don't be tempted to dismiss the multiple and often ghastly examples of medical error catalogued by these programmes as outliers in a healthcare system that usually operates safely or as a tendentious list compiled by a producer with an axe to grind. They're not. The Harvard medical practice study kicked away these props to our self esteem 10 years ago when the results were published in the New England Journal of Medicine. It reported that adverse events—defined as injuries caused by medical management that prolonged duration of admission or produced disability at the time of discharge—occurred in nearly 4% of hospitalisations. These findings have been replicated since. Now there's anger that the medical profession has been so slow to respond, and pressure on government to force change.

The first programme, called “A critical condition,” sets out the scale of the problem. It is estimated that 320 000 adverse medical events occur in the United Kingdom each year. Of these, 40 000 result in the death of the patient, a figure 10 times greater than the number of people dying in road traffic accidents.

The second programme, “The usual suspects,” demolishes the idea that the cause of medical mistakes should be attributed to the failure and incompetence of individual doctors. It is less coherent than the first but, even so, its point comes across. Medicine and surgery are inherently risky. Their practice depends on humans, who, we know, are all too fallible. Yet these things are equally true for air travel or the production of nuclear power. Both these industries have systems in place to detect and record error and to learn from mistakes. The Aviation Safety Reporting System in the United States analyses about 30 000 reports of near miss situations every year. The purpose is not to identify and punish individuals but to investigate what went wrong so that changes can be made that will reduce the likelihood of the event happening again. Their reports never conclude by simply exhorting pilots to be more careful.

The third programme, “Breaking the code of silence,” explores why medicine has failed to embrace such a system. It criticises a medical culture that encourages doctors to cover up errors for fear of retribution instead of owning up. It points the finger at the hierarchical system that penalises juniors for questioning their seniors' decisions. The programme attacks doctors' acceptance of patients' belief that they know best. It also condemns the ease with which many medical mistakes can be concealed, the apportioning of blame according to the gravity of the injury rather than the seriousness of the mistake, and the high personal cost that whistleblowers nearly always have to pay.

Lawyers also get some stick. The late Lord Denning is accused of political expediency over a decision in the Court of Appeal many years ago. His ruling is interpreted as a deliberate act to protect the newly formed NHS from legal action by patients.

This series will be uncomfortable viewing for doctors. For a start, it's bound to prompt painful memories of their own disasters. And, though they won't like the way that the point is made, they'll find it hard not to admit the truth of the central argument—that the way the profession currently deals with medical mistakes is not in patients' best interests, nor for that matter their own. 

I haven't seen the last of the four programmes. The videotape sent by Channel 4 had the right label but, when played, showed a historical documentary about railway disasters. After three hours of watching my profession being castigated for making mistakes and not having systems in place to prevent them, I was ridiculously cheered up by the fact that another complex organisation couldn't get everything right either. I watched it anyway only to find that its theme paralleled what I'd seen earlier. It was about how, over 150 years, railway travel had evolved from being quite a risky business into one of the safest ways of getting around. Analysis of the causes of train crashes had led to the introduction of systems that minimised the consequences of human error: signalling networks that prevented two trains being on the same length of track at the same time, fail-safe brakes that came on automatically if power was lost, coupling devices that remained coupled in the event of an accident, and carriages designed to withstand heavy impact.

If you can't face watching a series on medical mistakes, try to catch Derail instead. The message is pretty much the same.