Issue 18 / 20 May 2013

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 to obtain a copy of the original.



14 thoughts on “Elliot Rubenstein: The cost of safety

  1. Sue Ieraci says:

    There are real hurdles in bringing the public and politicians on board in our risk-averse society – error is not tolerated, and politicians must be seen to be “doing something”. It only takes one case of an addicted doctor or the death of a child on the front page for heads to roll and new procedures to be imposed. In a risk averse society, being seen to do something trumps common sense.

  2. Elliot says:

    Hi Wilson, I firmly believe that the only thing that makes an impression on the people who make the rules is a threat to their jobs. That, for a Pollie means votes. That occurs through widespread public outrage. Organizations like GetUp, newspapers and the media are generally capable of stirring this reaction if they can see value for themselves. Doctors best hope is to drive the message home whenever they can with patients, it’s the cost of their health care, friends, and any one else thy might know who is not bored to death by stuff which is not directly about them. So tell every body!

  3. Wilson Lim says:

    We have lost this battle a long time ago. We lost it when we didn’t object to the first silly incursion! There is no going back while the lawyers are whipping the risk adversed managers and doctors to greater and greater heights of waste. then we can add some of the findings by coroners who are almost all lawyers. I find it strange that a lawyer can make sweeping judgments on medical practice but I never see a doctor who has been appointed a judge or attorney general. The only way is to down tools and stop work on the basis that what the beaurocrats are asking us to comply with is just too silly.

  4. Elliot says:

    Hi John
    You may not be aware that one of the major forces that led to the closure of the Dandenong Surgicentre, the first free standing day surgery in Australia, was the need to meet new standards and install expensive new sterilizers. We now have the amazing situation where specialized day surgeries that may have had one or no cases of infection in thousands of cases have to meet standards similar to those of a tertiary institution.

  5. John Rehfisch says:

    I agree with Elliot and would suggest that the removal of “Flash Sterilizers” is another poorly thought through “move to improve the standard of care”. It has led to hospitals having to buy huge amounts of surgical equipment due to the long turn-over times for re-sterilization of instruments used in a case.

  6. Elliot says:

    Richard Emmett I think you have made a most pertinent point. There is no incentive to do anything different and there is, sadly, a benefit in not trying to change any thing. People will do things for money, for attention, for power or for popularity or pleasure. Not for other people’s benefit, and not often for very distant or remote benefit. The waste in hospitals does not cost the waster and it is doubtful that saving that waste would make much difference to them so why bother. How can we develop an incentive to save?

  7. Richard Emmett says:

    Anonymous – an insightful comment, but not a new concept. There are countless examples in industry of successful system-changes (whether driven by safety or efficiency motives, or both) where the people who are the users of the system also have a vested interest in the change itself, usually an economic benefit. The challenge in the public system remains how to “incentivise” change. There will always be a disconnect between medical bureaucracy and clinicians (unless they actually wear both hats), so it will always be a challenge for us to incorporate meaningful quality improvement into our individual practice while still trying to promote system -wide change. Putting up with silly knee-jerk responses (the management of S8 drugs in theatre is just one example) is probably a matter of choosing your battles. Every time I phone Telstra and speak to a well-meaning off-shore employee I am reminded of the benefit (detriment) of dealing with people who (don’t) actually use the product they are selling or supporting.

  8. Andrew Crawford says:

    I think a root cause in many issues of this type is that we have a self-perpetuating and self-interested “risk & quality” industry. “Risk reduction” and “Quality improvement” are not ends in themselves and we should not have departments devoted to these ends. It should not be possible to make careers in these fields, as they are not end products.

    I suggest,
    1) Risk & Quality departments be subsumed into departments of Medicine, Nursing, Surgerty etc
    2) That these departments be staffed by secondment only, for a max of 2 years. Front-line workers could spend some time in R&Q, make improvements that they themselves would ultimately have to work under, and then return to their real jobs, perhaps refreshed by the change of scenery.
    I suggest that with this scheme, it woudl be far easier to maintain good outcomes while also avoiding the sorts of idiocies that we all see every day visited on the real workers.

  9. Elliot says:

    Thanks for your comment Kylie. Following some comments emailed to me by Robert Gordon I concluded that only public pressure on politicians would have any effect. To that end I contacted health reporters at three newspapers but have not had any response yet. I would think talking to patients about why their rebates are so small, (because without this waste they could be much higher), might help if they can be encouraged to speak with their local or federal member.

  10. Kylie Fardell says:

    Thank you for putting forward so clearly an argument that I’ve been trying to formulate much less elegantly for some time. In terms of the issue of potential solutions raised by Jon Karnon, you’ve inspired me to at least try and find out locally what policy underpins this process and address it with the author as a first step.

  11. University of Adelaide says:

    when stated so clearly, who could disagree? we can even estimate the additional health benefits that could be provided with the saved monies, if sufficiently large, that should be evidence enough that the they outweigh the potential harms of rare safety events.

    so how do we change the process? what specific steps do we need to take? ultimately, each hospital will have to make conscious decisions and actions to change their processes, but what is the first step? evaluated pilot studies? can these be organised at a local level or can these processes only change given top down permission? from whom?

  12. 121872@amamember says:

    There are a lot of nurses who think as little of the hoops we all go through to use a narcotic are a painful waste of time for all of us but they are more ‘rule bound’ than we are. I do believe it’s more related to a well meaning but foolish bureaucracy than to power games. The problem for us is how to make things more rational.

  13. gazzainsight says:

    Thank you, Elliott – spot on! One of the issues is that the governance system that looks at so-called ”incidents” is much less sophisticated than the clinical practice is it governing. We also can;t, in a system full óf compromises and ‘rationing, expect perfection, or the elimination of risk. Too often the enforced solution to an issue can be ‘doing to be seen to be doing’, doesn’t mitigate any specific risk, and creates another entire set of side-stream risks.  

  14. Q209072@amamember says:

    I couldn’t agree with you more.  No-one is ever going to make narcotics thief-proof in operating theatres.  All the regulations do is allow people with small intellects and disproportionate power to make our lives difficult, and slow down operating lists.  If you can’t get two doses out of an ampoule without contaminating one or both then you haven’t the brains to be giving anaesthetics.

    Our lives should not be ruled by administrators and nurses!

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