Elliot Rubenstein: The cost of safety

AN area of medicine that currently needs serious attention is the ever-increasing regulation of our professional activities.

Each time some medical disaster occurs there is a reaction often far out of proportion to the actual event.

We see this in other areas of life such as the response at airports to terrorist attacks. Someone secretes explosive material in a shoe and for years we have to take our shoes off to pass airport security. Lucky the response to the “underpants bomber” was a little more muted.

Although it may be unappealing, when reacting to a medical disaster, all costs must be taken into account when considering the risks and benefits of any new regulations. This will need a fundamental change of attitude to the primacy of safety above all else, even though in some cases lives may be at risk.

Our professional values dictate saving life as our primary aim and primum non nocere our noble ideal, but unfortunately in the real world this ideal is often not realistic.

Imagine if we applied it to road safety. We know that driving fast increases the risk of fatal accidents, so if we reduced speed limits to a maximum 35 km/hour the road toll would fall dramatically.

Beaut, but the costs would be astronomical — clogged roads, traffic jams, frayed tempers, excessive fuel consumption, increased CO₂ emissions, endless problems with wasted time, and so on. Instead we accept a certain level of risk and try to manage it with safer cars, better road designs and big fines when rules are contravened.

Now consider my specialty, anaesthetics, and the matter of schedule 8 (narcotic) drug use in theatre.

There have, over the years, been quite a few anaesthetists who have diverted these drugs for their own use. In general terms this cannot be a good thing. What do we do to prevent it?

We lock drugs in safes, we issue them one at a time, two nurses check that the right number of ampoules are in the safe and document what we have been given, and we document that we have received the drugs. We have a nurse to witness that we document and discard any unused portion of the drug. The same process is repeated each time we use these drugs, which is in almost every case involving anaesthetic care.

Of course, this is really hopeless. No one can watch what is happening to unused portions of drugs throughout an operation. Nurses have other duties. If an anaesthetist wants to, it is not difficult to get around this system so why go to such lengths?

Most anaesthetists who get caught up in these activities rarely harm a patient. There are rogue doctors and angry, evil malignant people in every walk of life. Making nurses the anaesthetist police is not going to change that fact.

Then there is the question of safety and waste. After every anaesthetic case all remaining drugs in open ampoules are discarded to prevent contamination. I throw out hundreds of dollars worth of sterile efficacious drugs every week and so does every anaesthetist, probably more than 1000 in Victoria alone — more than $100 000 worth of drugs down the drain every week, well over $5 million every year.

Aren’t there more sensible ways of dealing with this? Of course there are, but perish the thought that drug contamination risks might rise ever so slightly.

This is just one tiny example. There are lots of others. Our hospitals are centres of waste.

We have to stop just looking at our values as medical professionals, which are noble and good, and start looking at overall value. Trade-offs. What will happen if we reduce the bureaucracy, give people the right to apply their training without excess rules and regulations, offer guidelines but reduce protocols?

Anaesthetic risks may slide from 1:200 000 serious incidents to 1:100 000 — who knows — but we will certainly save billions which we can put to better use in health care, such as shortening waiting lists, and helping with chronically underfunded mental health and aged care.

 

Dr Elliot Rubinstein is an anaesthetist in Melbourne and has represented the Australian Society of Anaesthetists on the AMA Council.

This is an edited version of an unpublished article written by the author. Please email Dr Rubinstein at qwerty@bigpond.net.au to obtain a copy of the original.