One Saturday afternoon in spring 1993, anaesthesiologist Jan Klein rushed to the operating room. A pregnant woman, who had started a home birth, contracted serious pre-eclampsia and needed an emergency caesarean. The baby survived but after the operation, his mother was found to be brain dead. She had had epileptic fits during the operation and had suffered anoxia. Klein may have been there within the time standard, but it was still too late. Even though it was 27 years ago, this incident would remain with him his whole life.
Since then, Klein believes that all professionals that are needed for emergency caesareans should be in the hospital 24 hours a day. His message to pregnant women is just as strong. “Don’t give birth at home!” He knows that he is upsetting midwives with his position, but he has other priorities. “The safety of the child and the mother comes first.”
‘There are enough opinion spouters already’
Now that the Covid-19 death rates are shared daily, you almost forget that the figures of the Nivel and Emgo research institutes show that thousands of people die every year from avoidable errors in hospital care. Klein has researched medical errors for years. In 2009 he was appointed Professor of Patient Safety at Erasmus University and since 2014, has focused on healthcare technology in the Faculty of Mechanical Engineering at TU Delft. He was also a practicing anaesthesiologist up to 2018.
Not a corona expert
As Klein is so outspoken, he is always approached by journalists to explain medical errors. He is a familiar face on Dutch current affairs programmes such as Zembla, EenVandaag and Nieuwsuur. However, he intentionally stays in the background on the coronavirus. “I do not see myself as an expert on corona. Furthermore, there are enough opinion spouters already.”
Increasing the number of ICU places, using discarded or new ventilators and the looming shortage of the anaesthetic Propofol, are subjects that he will discuss. “You need to deal with these type of complex problems from different perspectives. However, there is often a lack of equal cooperation between the medical world and other disciplines such as technology.”
The Red Cross failed to properly care for a runner suffering heatstroke, and a culture of fear at the Ear, Nose and Throat Department at the Utrecht University Medical Centre are just two of the TV reports in which Klein was asked for his opinion. His media performances regularly led to cynicism and criticism from his medical peers and healthcare managers. The main thrust of the responses are: what are you complaining about; we have the best healthcare system in the world; and, we’re doing our best. Klein has always found these responses difficult, but he also understands them. “The healthcare system in the Netherlands is good. But it could be safer and it’s not that hard to do if you can see what goes wrong.”
The desire for perfect care
That said, learning what goes well is a new way of thinking in hospital care. Klein thinks this is unwise. “You cannot be certain that something goes well, so how can you build on this? Some hazards, such as bacteria, are literally invisible. As is the coronavirus.” He continues, “Propofol is being used a lot to keep corona patients asleep in ICUs, but it is very susceptible to bacterial infection. In someone who is seriously ill, blood poisoning is often not noticeable, but it can be fatal.”
‘Protocols are sometimes unworkable’
The desire for perfect care has slipped, says Klein. “We are suffering from enormous administrative obligations and this is shoving the very essence of care to the background. Protocols are sometimes simply unworkable.” He believes that it would be a good thing if, in the face of the corona crisis, there would be more understanding that professionals sometimes have to cut corners.
Translating protocols into workable situations is not easy, says Klein. “Doctors have to enter the discussion on equal terms. With nurses, technicians, hospital hygienists, managers. It is a challenge that doctors don’t enjoy.” Klein anticipates that some technological innovations will take off more quickly because of the corona crisis. “Technology can help us improve patient safety, but it can also help relieve doctors and nurses. Smart systems could, for example, monitor ICU patients in several hospitals at the same time. I foresee an important role for technical physicians. They can design these systems, but they can also assess patient data. Their work, in a sort of control room, could be compared to traffic controllers.”
Openness is crucial for patient safety
But we are not yet there. To his regret, Klein sees more and more bureaucracy and increasing fear. In his experience, the culture of fear hinders everything. “Openness is crucial for patient safety. A contributing factor is that doctors are still being trained with the illusion that if you do your best, you will not make mistakes. This simply does not hold true. Every doctor will make mistakes.”
Klein himself made his biggest mistake in the early 1990s. He did a nerve treatment procedure on an elderly woman with facial pain. She was also taking blood thinners. “According to the blood tests, her blood was thick enough so I administered the anaesthetic. But she had a brain haemorrhage and died a few days later.” He is quiet and shakes his head. “The principle at the time was still ‘see one, do one, teach one’. Completely irresponsible. It’s different today, but you carry a mistake like that with you forever.”
Technology as a cause of death
Klein is Professor of Patient Safety Engineering, but he is also critical about healthcare technology. “Technology has advanced healthcare but has also made it less safe. It is unfortunately underestimated how often technology is the cause of avoidable damage and death in hospitals. Research shows that surgical knives are used in very many ways. Twenty-seven per cent of surgeons in training have experienced complications resulting from the wrong use of a knife. This could cause organ damage, intestinal injuries and so on.”
Klein is very surprised that despite that, surgeons say that they don’t need training because they know how to work with the knives. I can’t help but think, ‘What!?’ I denounce the culture in which medical specialists think that they know everything. You can’t do it alone.”
‘Nobody is subordinate to medical practitioners’
Collaboration between medical practitioners and technicians is imperative. A case in point is the Erasmus Medical Centre in 2012. “Twenty-two patients contracted a bacterial infection caused by an endoscope. It appeared that part of the endoscope could not be cleaned properly. The apparatus and the procedures needed to be modified to make sure that it could be used safely.” Multidisciplinary collaboration is unfortunately not a matter of course, asserts Klein. If that collaboration does emerge, it must be on the basis of equality. “Nobody is subordinate to medical practitioners.”
Klein stopped working as an anaesthesiologist in 2018. “I put my heart and soul into the profession and still miss it greatly. The work of an anaesthesiologist is similar to that of a pilot. It is a top sport and I doubt if I would still be able to respond optimally in a crisis.” His Chair comes to an end in September 2020 when he retires and he will also stop his professorship.
His advice seems simple. “The best hospitals in the world are the hospitals where different disciplines work together as equals. The world has become so complex so listen to each other. We will then all benefit!”