October 29, 2015
The death of a young girl at British Columbia's Children's Hospital back in 1997 spurred Dr. Doug Cochrane to rededicate his career to improved patient safety and the reduction of preventable errors in healthcare facilities across the country.
The child died two weeks after a potent anti-cancer drug meant to treat her leukemia was accidentally injected into her spinal fluid instead of into an intravenous drip. Cochrane, a pediatric neurosurgeon at Children's Hospital, was part of the medical team that fought in vain to reverse the effects of that error and save the girl's life.
"It was a profound event to have a patient succumb as a result of the best intended treatments but where those treatments had failed this patient," Cochrane recalls.
"As an organization, the Children's Hospital went through great, great deliberations. We had courageous leadership form Pat Evans, David Matheson and our CEO, Linda Cranston, who came forward and described what had happened to this child in a very public way. I think it was the first time that we as an organization had taken a responsibility for the consequences for our actions where those outcomes were tragic."
Cochrane, who today is the chair of the BC Patient Safety and Quality Council, in addition to serving as the Patient Safety and Quality Officer for the province, remembers the experience as an alarming wake-up call both for himself, as a cocksure physician, and for the hospital.
"As an organization we had no idea that there was the possibility of creating this kind of injury. We thought our systems were foolproof. We thought that we had systems that were resilient and rigorous and we had people in whom we had absolute, and continue to have absolute, committed trust. And yet the system failed the patient. The system failed the organization. The system failed those individuals who were treating that patient."
In the aftermath of the little girl's death and the discovery of similar cases across North America, the Children's Hospital implemented a number of new safety measures, including changes to drug labelling. Meanwhile, Cochrane was undergoing a personal transformation of his own.
"For me it took me from the enthusiastic trainee who I guess had — well I'll be really honest — the arrogance to think that whatever we did was the right thing to do, and whenever we had patients who had poor outcomes it was usually because of what the patient had brought to the situation, to the sudden realization that actually what we did mattered in very concrete ways. How we organized what we did, how we paid attention to what we were doing. And as an individual, that has had a profound effect on the way my career has unfolded and the interests I've developed in the patient safety and quality world since that time."
It is sometimes said that modern medicine is burdened with an unfair expectation of perfection. Patients certainly have an understandable need to consider their doctors infallible. Cochrane brings an interesting perspective to the matter.
"The idea that mistakes can't happen in our healthcare system is not too far from the truth. When you think about how many successful interventions, how much is happening in community care or long-term care to keep people safe, people that are being rescued from illnesses that would have taken their lives 10 or 15 years ago … it really is quite amazing what people and teams and organizations can do.
"But we would be blind to ignore the fact that we are human and that mistakes happen. They happen because we are human and because of the way we think and the way we act and who we are and I don't think we can necessarily make systems mistake-proof, I just hope we can make systems that will catch the mistake before they do harm."
Cochrane is of the belief that most healthcare workers acknowledge errors quite freely; they just don't always do it in a public way that can help relieve them of the emotional trauma that sometimes only further undermines effective patient care. Many of those people — nurses, physicians and other clinicians — are confronting those mistakes in sleepless nights or heightened stress and anxiety at work and at home, he says.
"The impact of errors that have occurred, particularly when they occur by your own hand, is profound. It does wake you up in the middle of the night, you do ask questions about your capability, your competence: 'Can we do this? Can I come back and do this again tomorrow?' And I suspect there is process that people have to work through to incorporate what really is a grieving loss process. It's not only a loss in the relationship with the patient but it's a loss in self-confidence and understanding.
"I think one of the things I have learned is that you somehow need to have an organization that is sensitive to this. Because I would never ask for help. I might be pushed to find help, probably by my wife, but I would never ask. But what would make a difference is that a colleague comes up and says, 'tell me about what happened and tell me how I can help you.'"
Whenever possible, part of that healing process should include a face-to-face disclosure of the mistake to the patient or family, Cochrane adds. That's a conviction he's held since even before his experience with that little girl whose life could not be rescued.
"This was not the first event in my career where I've had the opportunity to recognize my own weaknesses, or my own limitations, and a system that wasn't on top of things. I can think of several examples where the comfort that it brought to me to be able to acknowledge this with the family, or with the patient, was tremendous," Cochrane says.
"I don't think it made it any easier at all for the family, it didn't make it any easier at all for the patient, and it didn't make it easier for me, but it made it different and it brought us to an eventual understanding of our respective roles and — in my circumstance I'm thinking of a particular example — where we could have been better, and we weren't. And that was the royal 'we' — me."
As a former chair of the Canadian Patient Safety Institute (now Healthcare Excellence Canada), Cochrane understands the value and immediacy of individual stories in the campaign to raise awareness for improving patient care.
"I wanted to share this story because it is such a profound story at so many levels. Clearly the most significant level is in the lives of the family and in the life lost in that child. But it's not just there. Children's Hospital is a different organization because of that experience. Children's Hospital takes care of its patients differently now in a way that is safer. Children's Hospital organizes and cares for its staff in a way that is different and is safer. And we've taken the approach to communicate our experiences and results to other individuals and organizations less they assume they would never be subject to such an event or such an error. And I think that's actually the marvellous opportunity that has come out of this absolute tragedy."
Cochrane hopes every new generation of healthcare providers comes into the system a little better prepared than their predecessors in understanding the strengths of health care as well as its limitations. He's encouraged by what he sees.
"I'm amazed at the current set of trainees that I'm exposed to on a day-to-day. They truly up my game. Because they're far better prepared and have a far better working knowledge of many aspects that relate to safe care. They are more insightful about themselves, they are more understanding of their own reactions, but they are also more understanding of patients and how to treat them and families in a way that is respectful. I think we are in a good position but I would want all of them to remember that we have an obligation. We're fortunate in Canada to have a system in which we have an obligation, not just as taxpayers but as providers, and that obligation is to make the system better and to make it safer for all."