After Harm: Medical Error and the Ethics of Forgiveness

Appendix

a p p e n d i x Reader’s Guide Paul B. Batalden, M.D., and Jeffrey L. Rice, M.D. These questions were developed to provoke inquiry into the themes of the book and may be useful to groups of health care professionals when they study it. The questions are keyed to the chapters of the book. Preface 1. What is the aim of this book? 2. What is an error? What is harm? What is a system? What are the possible relationships among and between them? 3. Systems designed to produce something are never designed to be ‘‘safe’’ first. They are designed first to produce what they are supposed to produce. It is hoped that they will also be safe at an acceptable level. The safety of the system usually relies on a series of protective methods and actions. The functioning of these protective methods is assumed, but often not known directly by the operator of the system. The limit of their safety may or may not be known by the operator. Most of the advanced systems of medical care are hazardous (i.e., they have the capacity to induce substantial harm). Workers are often engaged in trying to mitigate the potential for harm in these systems. What is the responsibility of ‘‘responsible medical professionals’’ to know the empiric limits of safety of the system? Is an ‘‘error’’ different when the harm arises from a known, predictable risk from when the ‘‘error’’ arises from an unexpected circumstance or unrecognized risk? What responsibility do medical providers have for trying to mitigate errors and harm? What actions or activities can they engage in to increase the safety of the system? Chapter 1. Narrative Ethics 1. Following medical harm, how might a provider’s lack of disclosure be construed as a ‘‘lack of compassion’’? 2. How is the patient’s ‘‘story, voice, and perspective’’ important in the context of clinical care? How does the patient’s story help clinicians develop what Hilfiker describes as ‘‘an ethical framework in which to work’’? How does the patient’s narrative compare and contrast with the ‘‘clinical account’’? 3. Does the use of the provider’s personal narrative condition the accounts of medical care-induced harm? How? Does a narrative about ‘‘who’’ is responsible diminish the contribution that the context or system might play? How might a ‘‘narrative’’ convey the contribution that the context and system might have made in the production of harm? 116 Appendix 4. How is the ‘‘view from below’’ (the one harmed) different from the ‘‘view from the side’’ (a person trying to understand what failed)? Do both views contribute to forgiveness? Chapter 2. Physicians’ Narratives 1. What types of stories can physicians tell after a patient has been harmed? How can physicians’ stories be used to inform medical education? How can they be used to affect patient care? 2. How does medical error interfere with the ordinary work of a physician—acknowledging the patient’s pain, listening to the patient’s voice, and responding to the patient’s needs? 3. How does disclosure support and build the patient-physician relationship? 4. Sidney Dekker, author of The Field Guide to Human Error Investigations, invites us to consider the difference between explaining system failure and excusing it. He suggests the value of ‘‘re-situating’’ oneself into the situation facing a person as the system failure is created, trying carefully to avoid the problem of hindsight bias—which makes understanding so difficult. Creating a story that helps explain the failure can help us learn about the processes that have been involved in producing the harm. How can such a story complement the narrative accounts of Hilfiker, Gawande, and Ofri? 5. While often referred to, the ‘‘hidden curriculum’’ can also be thought of as another example of the ‘‘experiential learning’’ described by David Kolb (fig. A.1). Where do the teacher’s and the learner’s values inform the learner’s experiential learning ? Compare and contrast the effect of observed behaviors and espoused values on what is learned. Chapter 3. Patients’ and Families’ Narratives 1. What is the ‘‘understanding’’ that patients want after health care–induced harm? What might be included in narrative accounts that might foster appreciation and understanding of the ‘‘view from below’’? Fig. A.1. Experiential learning model. Adapted from David Kolb (1984). Reader’s Guide 117 2. How can patient and family narratives be...