Commentary: The Bulovka case. Czech healthcare is blind to mistakes

The case of the tragic mix-up of female patients at Prague’s Bulovka University Hospital is a huge human tragedy and also a bad reminder that no risk can be completely eliminated, only always minimized.

We still don’t know the exact sequence of events that led to an insanely mistaken abortion on a healthy pregnant woman. But we already know something. We know that the tragedy occurred at a hospital that boasts a certificate of accreditation from the Joint Accreditation Commission. This institution is a pioneer in the Czech Republic in promoting modern standards of quality and safety of care. And its certificate should be a guarantee that the hospital has taken measures that minimize the risk of common mistakes arising from the organization of health care.

Furthermore, unfortunately, we know very well that we know nothing. That apart from these certificates, we have absolutely no reliable data in our hands about how many similar (albeit less tragic) mistakes are happening in the Czech healthcare sector. In which facilities and in which departments do they occur more often, and thus whether some of the facilities have a greater problem with security than others. Whether their occurrence is somewhere in the corridor of the international average.

In short, we have no choice but to be moved and outraged by (another) single tragic event and call again for its careful investigation at all levels, from criminal to procedural. But even such an experience does not fit into the broader picture. We don’t have any. We are blind.

As it unfortunately turned out, even the best standardized process set up according to the most rich domestic and foreign experiences does not help when several human failures and unfortunate accidents are connected to each other.

A step-by-step analysis of the hospital’s failure should be available in the coming days. But already today, at least from the statement of the head of the gynecology clinic, it seems clear that there was a multiple failure in identifying the patient.

A woman-foreigner reported to the staff in the waiting room after calling a stranger’s name. This erroneously “tied” her to the wrong documentation – including the request for anesthesia, the procedure itself, and also including the informed consent given earlier. And none of the assumed mechanisms could tear the unfortunate woman away from the foreign documentation. The doctor only found out that something was really wrong during the operation on the operating table.

It’s as if a stack of papers traveled through all the hospital processes, and that there are some processes, not the human-patient. This is exactly the situation that standardized procedures – set up and verified, among other things, in the accreditation process – are intended to prevent. How big a role the language barrier played in the mix-up, or more precisely, the reluctance of the staff to overcome this barrier during the required multi-stage verification of the patient’s identity, and how other coincidences or negligence contributed to the tragedy, all of this must be analyzed in detail. And communicate openly if possible.

In addition to specific damaged patients, similar mistakes also leave behind a number of other damages, especially if they are not treated well. Individual misconduct by doctors or medical staff can be dealt with at the level of compensation or criminal law, but the reputation of the teaching hospital and the credibility of the Czech healthcare system require much more.

Above all, it is necessary not to focus primarily on individual failure and the search for scapegoats in the ranks of doctors or nurses. But the wider view is much more important for the hospital. He says that despite all the measures, something like this could happen on Bulovka. This is not in itself a failure of the individual, but a failure of the care organization and related processes. Anyone who has ever sat in any corporation has a fairly clear idea of ​​setting up processes and their subsequent compliance. And hospitals are corporations where health and life are at stake.

If the hospital had its processes set up in such a way that they opened up space for an interplay of chance and individual failure that led to fatal patient harm, it had them set up wrong. And this should be of great interest primarily to the clinic management and the entire hospital management. And immediately afterwards also the founder of the hospital, i.e. Minister Vlastimil Válek. And last but not least, also the representatives of the United Accreditation Commission, because the reputation of their institution, or their accreditation process, is also at stake.

Mistakes in the healthcare industry do and will continue to happen. Most of them will remain hidden from the public eye because they will not take on such tragic proportions as the death of a healthy fetus. Still, we all know these mistakes happen. It would be highly desirable if at least aggregated statistics of extraordinary events and errors in individual medical facilities were available to the public. It is one of the many large Czech data debts.

Then it is the task of hospitals, their founders and quality and safety monitors to explain why errors occur and what is being done to make them as few as possible.