"Don't put your emergencies in a taxi!"
- Monica Alabi
- Jun 3, 2016
- 2 min read
"There is no end to learning,but there are many beginnings" T.Johnson
Most Healthcare staff all over the world strive to do the best for their patients.All should be treated fairly and according to approved guidelines irrespective of socioeconomic status,race,religion or sexuality.
Mistakes happen and when they do,years of medical training should have drummed it into all, that they are an opportunity to learn and avoid said mistake in the future.
No one likes clinical errors and certainly not when it comes to the handling of patients.Part of the recompense of working in Healthcare is seeing patients thrive.
When mistakes occur,accountability means that the personnel involved,with the support of management follow the agreed process of reporting.
Recently,I was rung by a friend who's staff had gone to have a baby in a Lagos suburb.The baby,born at term,had suffered lack of oxygen during the birth and was displaying signs of brain damage.The mother was told to take the baby to Massey street children's hospital.
This is where it gets interesting or shall I say tragic.The new mother had to take her baby home first in a taxi to get her father.They then proceeded in another taxi to the hospital.I'm sure everyone reading this and not just medics will be quite surprised at that.Time is crucial in Medicine.
There were no hand over notes given to the mother so they arrived at Massey with a very unwell baby and no idea of the history.
The neonatologist did all she could bearing in mind the room was full of other unwell babies that also needed her attention.However,despite her best efforts,the baby died.
No complaint was brought against the hospital and they have continued to practise unchecked.No learning has been gained and the system is weaker for it.
Statistics about neonatal/infant and child mortality are well documented here.
The focus however, is on the role of Clinical Governance in strengthening and improving the health system.Clinical Governance is a framework through which Healthcare organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating and environment in which excellence in clinical care will flourish.
In this case,a serious incident report is necessary.This will closely examine every step of the process,identify where mistakes were made and put in robust mechanisms to prevent a recurrence.
Health institutions agree their own process.Training is widely available.
An audit will then examine other births in the hospital and compare against set standards.This identifies any similar cases to the index case.The audit can then be repeated at a later date to see if changes made have been effective.This will be demonstrated by those mistakes being no longer present or being minimal.
Audit Cycle
This was a very tragic case and we all know that there are many more of these cases.Every life is valuable and this is the time to take some deliberate action.
This concerns all of us,everyone is a potential patient.
Let us put a stop to preventable morbidity and mortality by taking a different step today;focus on Clinical Governance.Strengthen your system,report poor practice and get some training.
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