LETTER TO EDITOR
Year : 2014 | Volume
: 58 | Issue : 6 | Page : 781--782
Learning from our mistakes: A case of a concealed history and a casual resident
Madhuri S Kurdi, Kaushic A Theerth
Department of Anaesthesiology, Karnataka Institute of Medical Sciences, Hubli, Karnataka, India
Dr. Madhuri S Kurdi
Department of Anaesthesiology, Karnataka Institute of Medical Sciences, Hubli - 580 022, Karnataka
|How to cite this article:|
Kurdi MS, Theerth KA. Learning from our mistakes: A case of a concealed history and a casual resident.Indian J Anaesth 2014;58:781-782
|How to cite this URL:|
Kurdi MS, Theerth KA. Learning from our mistakes: A case of a concealed history and a casual resident. Indian J Anaesth [serial online] 2014 [cited 2020 Aug 11 ];58:781-782
Available from: http://www.ijaweb.org/text.asp?2014/58/6/781/147186
Errors are an inevitable part of anaesthetic practice. Anaesthesiologists are humans and humans make errors.  A key component of reducing errors is to learn from previous mistakes.  We report here a case of medical error which thankfully did not lead to any mishap.
A 23-year-old primigravida with prolonged labour presented for emergency caesarean section. Records of previous antenatal visits were not available and she did not give any history of previous medical/surgical illness. Physical examination and basic investigations were assessed and recorded to be normal by the seasoned junior resident anaesthesiologist who later administered her spinal anaesthesia.
After the spinal anaesthetic was given and when the patient's chest was exposed for painting, the anaesthesia consultant noticed a long vertical midsternal scar. The patient on questioning revealed history of cyanotic episodes and exertional dyspnoea throughout her childhood and that she had undergone an open heart surgery 8 years back for the same. She added that she was asymptomatic since then and was not on any medication. The caesarean section was uneventful and postoperative echocardiography revealed no cardiac abnormality.
When the patient's previous records were sought we were surprised to find that her spouse and in-laws were unaware of her previous illness. With great difficulty, we obtained the records from her parents. The records showed that she had been operated for ventricular septal defect with pulmonary stenosis and right ventricular hypertrophy.
For anaesthesiologists, the need to do more with less has produced a strong cultural acceptance of multitasking in a teaching hospital. Staff anaesthesiologists often cover two operating rooms simultaneously, supervising trainee anaesthesiologists who are dedicated to each room.  This might be one of the factors contributing to the error in our case. Furthermore, hurried circumstances and the speed of trying to get the case started can contribute to unsafe practices by the anaesthesiologists.  Ours was a case for emergency caesarean section and the surgeons were very eager to start the case. Nevertheless, inaccurate history taking due to lack of personal contact with the patient was possible in our case.
The pre-anaesthesia evaluation time is crucial and it involves a high workload.  It is often the most hurried and this combination may set practitioners to make errors, which could have happened in our case. A gruelling schedule leading to sleep loss and fatigue are commonly reported in interns and residents. These can lead to neurobehavioural impairments in them leading to errors. 
As regards the initial incomplete history given by our patient, it is obvious that the woman and her parents viewed her heart surgery as a stigma and adopted concealment as a coping strategy.
Errors and misses like this can sometimes be catastrophic and at such times there can be no legal protection. After the occurrence of an error, it is ethical to disclose the true and complete nature of the error, as to how, why, where and when it occurred, and the necessary measures should be taken to avoid it in the future.  Reporting such incidences can later trigger warnings and ultimately create a culture of safe practice. Auditing such incidents, through meetings and gatherings, will help us in comparing what is done against the accepted reference standards and hence that corrective steps to improve performance will emerge  and help us progress in our learning curve.
Multitasking should be avoided and systematic pre-anaesthesia evaluation with better personal contact during history taking and a detailed physical examination with strict avoidance of shortcuts even in an emergency situation should always be done. After assessment and before starting any case, always ask oneself "Have I missed anything out?!!"
|1||Hardman JG, Moppett IK. To err is human. Br J Anaesth 2010;105:1-3.|
|2||Gravenstein JS. How does human error affect safety in anesthesia? Surg Oncol Clin N Am 2000;9:81-95, vii.|
|3||Espin S, Lingard L, Baker GR, Regehr G. Persistence of unsafe practice in everyday work: An exploration of organizational and psychological factors constraining safety in the operating room. Qual Saf Health Care 2006;15:165-70.|
|4||Veasey S, Rosen R, Barzansky B, Rosen I, Owens J. Sleep loss and fatigue in residency training: A reappraisal. JAMA 2002;288:1116-24.|
|5||Patel I, Balkrishnan R. Medication error management around the globe: An overview. Indian J Pharm Sci 2010;72:539-45.|
|6||Harsoor S. Critical incident reporting and learning system: The black pearls. Indian J Anaesth 2010;54:185-6.|