Saturday, July 28, 2018

Everything I do, I do it for you (Musings on the UK's Bawa-Garba case)

In July's blog I offer brief comments on an item in TraQ's July newsletter. The title derives from Canadian Bryan Adams' 1991 song.

UK's Bawa-Garba case, dating to 2011 and still unresolved, has gained attention of health professionals worldwide (right click, open in new tab,for clearer graphic).
Source: What impact will the Bawa-Garba case have on community pharmacy? (Further Reading)
Source: The Bawa-Garba case, BMJ (Further Reading)

The case gives rise to so many points of discussion, including
  • Racial bigotry;
  • Culture of blame vs encouraging health professionals to report errors honestly without fear of reprisal;
  • Responsibilities of senior staff supervising junior staff;
  • Consequences of one serious error by an otherwise competent practitioner;
  • Stifling the recording of written reflections about mistakes made (tool for personal learning) because they may be used in court;
  • Facility responsibility for errors made by overworked staff in understaffed health facilities;
  • Should public perceptions trump justice and dictate harsh sentences so faith in the safety of the health care system won't be lost.
As an ex-med lab science (transfusion) educator, I'm especially interested because I was involved in case where a student error hastened a patient's death:
  • TraQ's Case A8: Severe Hemolytic Transfusion Reaction Involving a Student (Further Reading)
Also, earlier as an experienced medical technologist in a stand-alone central transfusion service separate from hospitals, and working alone on a Saturday night, I once crossmatched a pre-op patient who surprisingly typed as group AB when records showed she was group O. The SOP of always checking prior records saved that patient as another sample was drawn at the hospital, which correlated with the historical group.

But what if I had been distracted or swamped by an emergency and somehow did not do the required patient history check? A disaster (serious hemolytic transfusion reaction) might have occurred, perhaps leading to patient death, and it would be due to my error for not following standard operating procedures. Perhaps I would have been charged with gross negligence manslaughter due to not doing what a reasonably competent technologist would do?

The Bawa-Garba case offers food for thought for all health professionals.

My lifetime experience is that health professionals put patient safety above all else and often sacrifice much to perform health care duties in an exemplary manner. That includes long years of study as students and, once registered, investing much personal time to keep up-to-date with the latest advances and best practices.

Could not resist using Bryan Adams' 1991 ditty, the third best selling Canadian single of all time:
What impact will the Bawa-Garba case have on community pharmacy?
The Bawa-Garba case, BMJ
Bawa-Garba news items (TraQ's 2018 July newsletter)
TraQ's Case A8: Severe Hemolytic Transfusion Reaction Involving a Student 
As always, comments are most welcome.