Every year, about 5.2 million people die due to human errors in India. Even in the US, the figure is not less than 44,000 to 98,000. It is not lack of medical skill or knowledge of doctors, but that of team coordination and communication during an emergency that lead to medical errors.
Deaths are a result of miscommunication
When two year-old Ananya (name changed) was rushed to a hospital near Bengaluru at 10.30 pm, she was unable to breathe, had runny nose, cough and cold for three days. The doctors at the emergency section found her on the verge of having a cardiac arrest and alerted their crisis team, Code Blue, to bring in more helping hands and expert doctors at her bedside. However, only two doctors out of five could reach on time.
“Luckily my daughter survived, but she could have had a fatal attack due to dearth of doctors in the emergency. When the incident was analysed, doctors reported that the announcement system in the hospital was not working that day,” Ananya’s mother said about the lack of coordination among doctors and nurses in the emergency unit.
The situation was similar when Raghunath (name changed), 4, was taken to the emergency unit of a hospital with fits and high fever. After he was given a medicine to stop seizures as per the doctor’s order, Raghunath stopped breathing. A breathing tube had to be immediately inserted and he was shifted to ICU. Later, it was found that the nurse attending Raghunath had recently joined and could not follow the doctor’s order clearly. Raghunath received an overdose of medicine, about three times more than the normal dosage, which affected his breathing.
“Every year, about 5.2 million people die due to human errors in India. Even in the US, the figure is not less than 44,000 to 98,000. It is not lack of medical skill or knowledge of doctors, but that of team coordination and communication during an emergency that lead to medical errors. Around 70% of deaths that occur due to medical negligence can be attributed to human errors,” said Dr Rakshay Shetty, paediatric intensivist at Rainbow Hospitals, Bengaluru. He, along with a few colleagues, set up the Paediatric Simulation Training and Research Society of India (PediSTARS) in 2013 to train doctors and other healthcare professionals on the use of simulation technology for better and safer handling of patients.
PediSTARS has conducted around 24 workshops across the country for around 830 doctors and 210 nurses.
Opinion of Dr Sujatha about miscommunication
Dr Sujatha Thyagrajan, paediatric intensivist at Rainbow Hospitals and a founding-member of PediSTARS, said: “The idea behind these trainings is derived from the aviation industry. We create most of the common emergency scenarios using high-functioning mannequins which act as simulators. These simulators can breathe, can talk and their pulses can be felt. They respond to treatment like in real situation. Medical teams comprising doctors and nurses face these scenarios and discuss how to improve their performance.”
Dr Dhananjay Mangal, a paediatrician from Jaipur who recently attended one of such workshops said, “This training helped me save a very ill baby who otherwise would have died. We find this the most realistic way to learn to tackle emergency situations .”