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“Learning Early on that Everybody Makes Mistakes”
Sometimes doctors forget surgical
instruments in the abdomen of the
patient; © SXC
MEDICA.de: Mr. Schrappe, “Learning from mistakes” is the title of one of the brochures from the German Coalition for Patient Safety, which you have chaired for many years. In this brochure, doctors talk openly about forgotten clamps in the abdomen and wrong patience diagnosis. You also confess in it to a medical error.
Matthias Schrappe: Yes, that was in my first year as a resident physician. A young patient appeared extremely agitated and complained about heart palpitations. I thought about all sort of possible causes, but not about a pulmonary embolism. When I heard about the diagnosis, I got very scared. I wrongly interpreted the symptoms, probably due to inexperience. During a meeting the next day I talked about my mistake, but my boss didn’t place any further attention on it and simply continued with the order of the day. At the time, this really irritated me. After something like that you are very emotionally agitated and you want to talk about it- also with the intention of preventing something like this from happening to other colleagues.
MEDICA.de: Why is it a particular concern of yours to talk publically about error in treatments?
Schrappe: For many years, I have been dealing with healthcare provisions and Quality Management in hospitals and one should lead by distinction. Mistakes are an important aspect of patient safety, and if you talk openly about them, then you can learn from them. This is also a focal point of the Coalition for Patient Safety, which was founded in 2005. In particular, their goal is to reduce mistakes by making action recommendations.
MEDICA.de: What is written in those recommendations?
Schrappe: For example, doctors are asked to pay close attention to count the amount of swabs, clamps and bandages before and after the surgery. It is very important to stop proceedings in case there are any doubts. Doctors should work like pilots. If something isn’t right on a plane, any further actions are interrupted while the problems are being checked into. If doctors work systematically like that, they will locate a forgotten swab in a patient’s abdomen much faster.
MEDICA.de: Since January 2009, the University of Bonn has its own Institute of Patient Safety, funded by the Coalition for Patient Safety. Why is it so important to deal with this topic from a scientific basis?
Matthias Schrappe; © IfPS
Schrappe: The Institute is supposed to check by using scientific methods, whether the practical work of the Coalition contributes to more safety. There is a lot of interest in these recommendations, especially from patient alliances, but eventually the question comes up whether those recommendations result in fewer treatment errors. This is what the University is supposed to find out. That’s why we conduct studies in cooperation with hospitals all over Germany. Initially, those projects are planned for a duration of five years. Long term, we hope that the Institute will be accepted into the normal academic system and its work will continue.
MEDICA.de: The primary goal of the World Health Organization (WHO) is to reduce mistakes by using a specific surgery checklist. For some clinics, this list is already part of their daily routine. In your opinion, is this measure still not enough?
Schrappe: The checklist of the WHO is certainly an important tool for patient safety, but it is very general and broad. It is a checklist which asks about different things, for example whether you are operating on the right patient, at the right location, and whether all surgical instruments and equipment is completely accounted for after the surgery. With our recommendations, we want to go into even more detail and find out, whether there is a specific way to prevent a swab or bandage from being forgotten in the abdomen.
MEDICA.de: Do you want to establish those recommendations in the health care system if the studies provide good results?
Schrappe: That is not in our power. And there is no existing law for it either, but we hope that this develops its own momentum and more and more clinics will use these guidelines. This way, standards can develop over time without any laws.
MEDICA.de: The Institute for Patient Safety in Bonn is the first facility of its kind in Germany. Was this topic not considered important enough in the past?
Schrappe: You can say that. Quality- and patient safety research have long been neglected in Germany. Slowly those areas are garnering more attention. The Institute’s foundation therefore is a huge success and not only an important step for Germany, but also in an international context. I know of no other comparable research facility like this in Europe.
MEDICA.de: Will your Institute’s findings find their way into medical studies at Universities?
Schrappe: That is definitely our goal. Even though it is difficult to introduce a separate subject for patient safety, since medical students already have to take many subjects and have lots to study. But you could integrate the topic into other subjects and study a few hours of patient safety in the subjects of “Internal Medicine” and “Surgery”. This is very important, so students learn early on that everybody makes mistakes and that they won’t be spared from it either. We also hope that in the future this topic will find its place in the Medical Licensure Act.
The interview was conducted by Simone Heimann and translated by Elena O`Meara