She said there was the need for healthcare facilities to study their systems and identify gaps to prevent such mistakes. Dr Penstil was delivering the 12th Lecture of the Accra College of Medicine at Adjiringano on Wednesday on the theme: ‘’Medical Errors — Root Cause Analysis’’.

The monthly lecture was to offer the students, medical practitioners and health administrators insight into medical errors, recognise the importance of identifying root causes of errors and outline steps for their analysis.  Dr Pentsil said: ‘’We need to look at our systems and figure out our loopholes and what we can do to prevent those from happening’’.

She stated that root cause analysis was important because it opened windows of understanding of what happened in order to solve it. Dr Pentsil said medical errors contributed significantly to morbidity and mortality in both in-patient and out-patient settings.

“In May, 2014, there was a report of a medical team leaving swabs in a patient’s abdomen after a laparotomy in a reputable hospital. Later, the patient died out of complications from the negligence,” she said. Dr Pentsil said such a situation necessitated root cause analysis because ‘’if we do not understand how it happened we can never solve the problem.”

She said the human resource was very important in situations like this because at some point someone had to be responsible to make sure that everything was well set out and accounted for in the theatre. ‘’We also need to pause the system and understand the fact that the medical items are part of what we do in the theatre. Until we start enforcing these things as humans we will continue to commit such errors, knowing we can get away with it,” she said.

Dr Pentsil said root cause analysis helped to identify existing problems, understand current processes, formulate solutions theories, establish improvement targets, select and implement solutions, as well as set up monitoring systems.   

A school of thought on medical errors hold the view that persons found culpable should be punished to serve as deterrent. Dr Pentsil held the view that while punitive measures were very important, a structured systems would make such errors avoidable.“If no one is adhering to the system put in place so that no one leaves equipment in patients, this is where you need to put in place systems because human behaviour will not change.

Dr Pentsil admitted that while there may be challenges with hospital’s equipment in Ghana, the bulk of errors are not because of equipment adding that it may be one of the reasons, but not the only reason.