JOINT STATEMENT FROM INTERNATIONAL ORGANIZATIONS

THE UNITED NATIONS and the World Health Organization recently issued a joint statement claiming that the deaths of 15 children during a measles vaccine campaign in South Sudan were due to “human error.”

This is nonsense. According to facts that have been released, this tragic event is the result of decisions by people in high places, not honest human error among those administering the shots.

ACCIDENT INVESTIGATIONS

Medical mistakes happen for many reasons, and accident investigators usually take great care to accurately distinguish between honest human error, willful negligence, and system errors. Root causes for each type of failure are different, which ought to be reflected in our responses to them.

To say that a medical mishap is a result of human error is to say that the failure stems from the type of momentary slip or lapse to which we are all prone—such as pouring orange juice rather than milk into our morning cup of coffee.

Human error is likely the culprit when a nurse forgets to swab a patient’s arm with an antiseptic wipe before inserting the needle. She knows better and may even realize right after pushing the needle through the skin barrier that she goofed.

Honest human error is common and is actually inevitable. It happens every day, even among the most gifted health care professionals. Up to 50 percent of the nearly half a million preventable deaths that occur in U.S. hospitals each year involve honest human error.

HUMAN ERROR IS COMMON IN MEDICINE TODAY

Rushed and tired, health care professionals are prone to forget to wash their hands or double-check a medication label, and there is usually nobody nearby who is equipped to provide a much-needed reminder or nudge to do the right thing. So, mistakes are made, and patients are sometimes harmed.

Medical mishaps rarely result from willful negligence. You would be hard-pressed to find a doctor, nurse, or technician who goes to work planning to harm patients by delivering substandard care. More typically, the health care system sets the stage for human error.

For example, there is a direct correlation between medical errors and the nurse-to-patient ratio on a given hospital unit. If a hospital chooses to grossly understaff a unit, blaming a lack of attention to detail on the inadequacy of an individual caregiver might be misleading.

HUMAN ERROR VERSUS SYSTEM ERROR

To prevent recurrence, health care organizations must find and fix the root causes of medical mishaps. This requires a willingness to face the truth, even when doing so is uncomfortable. The joint statement by the U.N. and WHO about the recent measles vaccine debacle does not inspire confidence that such a tragedy will not be repeated.

According to a June 2 story in the Los Angeles Times, an investigation by the government of South Sudan “found that the needles were dirty, used repeatedly to inject different children, and the vaccines were not refrigerated, with unqualified workers administering the vaccinations.” The root causes of the vaccine-related deaths in South Sudan clearly reflect system issues, not honest human error.

HOLDING THE RIGHT PEOPLE ACCOUNTABLE

We must not allow ourselves to be distracted by the shock of learning that dirty needles were repeatedly used; we must focus on who was allowing this to take place—especially since the program continued for weeks after problems were identified. And, we should ponder why the U.N. and WHO would jointly blame the death of 15 children on honest human error rather than addressing the system-level culprits.

The content of this article first appeared in The Virginian-Pilot on July 2, 2017. 

References

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