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SPECIAL REPORT
Time for
change
Mandatory reporting of medical errors must
be introduced to improve patient safety, says
Rebecca O’Malley. Alison Moore reports
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WIN June 2008 Vol 16 Iss 6
A CHANGE in Ireland’s hospital culture is
required if medical errors are to be identified and rectified at the earliest opportunity.
This was the opinion of Rebecca O’Malley,
the Tipperary woman at the centre of the
recent HIQA investigation into her breast
cancer misdiagnosis, who addressed the
INO’s annual delegate conference in Cavan
last month.
Ms O’Malley, who was wrongly given the
all clear from breast cancer, called for the
introduction of mandatory reporting of
medical errors and potentially unsafe situations. She felt that there currently existed
a “very frightening culture of ignoring
cries of alarm when it comes to patient
safety”.
The keeping of such information quiet,
whether as a result of the fear of repercussions or a desire to protect oneself,
according to Ms O’Malley, would only
serve to perpetuate the “commonly perceived culture of silence and secrecy that
exists in our health service that we so desperately need to change”.
Her story
Recounting her own story, she recapped
on the circumstances surrounding her
case. She was referred to a local breast
clinic in spring 2005 after her GP had
found a small lump in her breast and was
subsequently given the all clear after
undergoing clinical examination, mammography, ultrasound and a fine needle
aspiration biopsy.
A year later the symptoms were still
there so she was again referred to the
same clinic and in June 2006 was told she
had invasive breast cancer and required a
full mastectomy. She then had her treatment in London where she underwent
eight rounds of chemotherapy as well as
axillary clearance surgery as the cancer
had spread to her lymph glands.
Ms O’Malley told delegates that she
wrote to her consultant raising concerns
about her 2005 diagnosis, as she could not
understand how the cancer could have
advanced so far and so quickly after the all
clear had been given.
Although the consultant agreed to
requests for a review of those tests it was
another five months before she was called
back to the hospital and told that one of
the tests had been misdiagnosed. Concerned that that there might be other
women who had been similarly misdiagnosed but didn’t know it, she wrote twice
to the hospital delivering an ultimatum
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that if she didn’t get assurances that there
would be an independent investigation
she would go public.
It would have been easier for Ms O’Malley to stay quiet but she knew that going
public was the “right thing to do”.
“If I had instead chosen to continue
writing my letters to the hospital I might
have eventually received some limited
and ‘safe’ answers, but I am certain that I
would not have been provided with such
a revealing window into the dysfunctional
workings of the HSE that the HIQA report
eventually provided,” she said.
Important role
Nurses, she said, had an important role
to play as patient advocates.
“The unique relationship between
patients and their nurses is underpinned
by the patient’s vulnerability and the
nurses’acute awareness of and compassion
for that vulnerability. This creates a natural
order that dictates that it is the nurse who
is best placed to speak up for the patient
when, because of illness and infirmity, the
patient’s voice cannot otherwise be heard.
That is a role you nurses cannot allow
yourselves to shirk from even when under
fear of reprisals,” Ms O’Malley said.
She added that she had spoken to a
number of nurses who told her that there
is a climate of fear in the health service
that hinders them from speaking out on
behalf of patients. She said that the “abuse
of temporary contracts” had created an
“insidious obstacle” to nurses’ freedom of
expression, with a pervasive message of
“stay quiet, stay subservient”.
As a profession, she said that nurses do
not have a choice in this area. As the primary advocate for the patient, nurses
must say what needs to be said.
“Once you abdicate that role as the
patient’s advocate, then the whole foundation upon which your profession is
founded and why it has enjoyed such historical and continuing high respect, will
have crumbled,” she warned.
“I would hope that the INO will send out
a clear message that it will not tolerate or
support any nurse manager who is found
to have victimised one of their own nursing colleagues who has raised bona fide
concerns about patient safety. It surely
must be professional misconduct of the
highest order to conspire against patients
by victimising nurses who have taken the
brave and honourable step of speaking up
for the safety of their patients,” she added.
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Mandatory reporting
Although admitting to having made a
mistake is the right thing to do, Ms O’Malley observed that it is not always the
easiest thing to do. What makes it particularly difficult for nurses, she said, was the
“prevailing culture that makes them fearful of the repercussions of doing so”.
“Neither of those reasons justifies not
admitting to having made a mistake but
something has to change to make it easier
and more acceptable for everyone to
engage in disclosure, she said.
Two approaches, she said would help
change the culture.The first was education
and the second was new legislation that
makes it mandatory to report medical
errors and potentially unsafe situations to
the patient and to an independent register.
She strongly believed that the introduction of mandatory reporting of medical
errors would send out a “very clear message” to patients that the health services
in Ireland were committed to improving
patient safety and were resolved to put
patients first.
“The prevailing culture, instead of
encouraging healthcare workers to admit,
report and analyse errors and obtain help
coping with the emotional impact of harming a patient, has instead isolated them
and promoted fear,” Ms O'Malley said.
“We have to do things differently. If we
do what we have always done then we
will get what we have always got,” she
added. She argued that in the 21st century, not informing a patient of mistakes
just serves to perpetuate the perceived
culture of silence and secrecy .
While there is a view that reporting
errors should remain voluntary because a
mandatory system could demotivate
healthcare workers, Ms O’Malley pointed
to other areas, such as the airline industry
and health and safety, where this is not a
factor.
Future
Urging delegates to read the HIQA
report on the investigation into the circumstances surrounding her case, she
spoke of the scale
of problems it
uncovered in the
areas of communication, accountability,
managerial and clinical governance and
leadership at two major hospitals and the
wider HSE.
More positively, she said that the report
also provided 15 recommendations that
would do much to make breast cancer
diagnosis safer, develop governance and
leadership in hospitals and improve
safety and accountability within the
health service.
“Whilst I have this opportunity, I want to
thank the INO most sincerely for the support you have pledged in backing each of
the important recommendations. The
more people that take on board the
essential messages contained within this
HIQA report, the more learning will have
taken place and the better the health service will be as a result,” she added.
HSE spin
Referring to what she believed was the
HSE’s attempt to ‘spin’ the HIQA report into
a good news story, Ms O’Malley sent a
chastising message to Prof Drumm, warning him that as long as she had the
“faintest breath in her body” she would
use her voice to urge for that change of
culture in the HSE.
“Your organisation failed me as it has
failed many others with breast cancer.
Your organisation then ignored me as it
ignores many others who seek answers to
legitimate questions about their health
and treatment.
Her final words however, were for nurses.
She said that while the patient’s voice was
getting stronger, they still needed to rely
on nurses to speak up for them.
“We still, and always will, rely so heavily
on you, our nurses, not only for our care
but to speak up and advocate on our
behalf, especially in matters relating to our
safety. You must not, and, in my heart, I
know that you will not, let us down or ever
abdicate that unique and ever so special
role,” she said.
Ovation: INO
delegates at the
ADC in Cavan
take to their feet
following Rebecca
O’Malley’s
(pictured left)
passionate
address to the
conference
WIN June 2008 Vol 16 Iss 6
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