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Foreword
- Johns Hopkins University Press
- Chapter
- Additional Information
vii The driving concept behind the modern patient safety movement is simple and powerful: errors are caused by bad systems, not by bad people. Actualizing this notion has proceeded in two major directions: creating a non-punitive environment where it is safe to report and talk about mistakes and making changes to the bad systems. Success in both dimensions has been highly variable, and at times slow, although there have been some spectacular successes, such as the virtual elimination of certain types of hospital-acquired infections. Coincident with the increase in awareness of the extent of preventable medical injury, and undoubtedly facilitated by the discussion of efforts to change systems, has been the rise of patient advocacy groups, such as Consumers Advancing Patient Safety (CAPS), Medically Induced Trauma Support Services (MITSS), Persons United Limiting Substandards and Errors in Health Care (PULSE), the Josie King Foundation, and Mothers Against Medical Errors (MAME).These organizations have been founded by individuals who were injured by or who lost a loved one to a medical error. Although most of these organizations seek to improve the safety of medical care, the stories the founders tell are less about injury and mistakes and more about how they were treated when things went wrong. The common themes are stonewalling of information, refusal to take responsibility, and refusal to admit error or apologize. Thus, the major focus for these groups has been on efforts to improve communication and support. Rather than sue, they seek to mobilize public opinion to force change. The time is ripe for change. We have long known that a serious medical mishap is devastating for the patient, imposing an immense emotional Foreword Lucian L. Leape, M.D. viii FOREWORD burden on top of the physical suffering and fracturing the trust that is the cornerstone of the doctor-patient relationship. And we know that honesty , transparency, and apology are essential to ease that burden and rebuild that trust. Yet, too often it doesn’t happen. In no aspect of health care is the discrepancy between what is known and what is practiced greater than it is in communicating with patients when things go wrong. Most doctors, I believe, are honest and communicate well with their patients . But too many do not, as the horrendous annual number of malpractice suits bears witness. Why? The reasons are complex, as you will come to understand reading this book. For decades, doctors and hospitals have been given bad advice by their lawyers, who have been more concerned (incorrectly, it turns out) about our liability than our humanity. But this advice to deny responsibility and avoid apology was not totally unwelcome to physicians. It fed into their fears of shame and disgrace and provided cover for avoiding the painful discussion with the patient and the revelation of fallibility. A complex psychology, abetted by longstanding peer-sanctioned tradition. Sadly, disclosure malfunction is but one example of a much larger problem: the dysfunctional culture of most health care institutions. For every instance of a patient who is lied to—for that is what failing to admit to and explain a serious medical error is—there are multiple instances of disrespectful treatment as well as disruptive, disrespectful, and even abusive conduct toward nurses, residents, and medical students. And even more instances of subtle, insidious, even institutionalized disrespect. Again, this is not the majority of physicians—far from it—but it is enough to “poison the well” and create an atmosphere of fear and distrust. No wonder that creating a non-punitive environment where doctors and nurses can safely report and discuss their errors has proved so difficult to achieve or that working together in interdisciplinary teams has also proved difficult. Changing that culture has been the daunting challenge of the safety movement. In this context, the insights and recommendations by Robert Truog, David Browning, Judith Johnson, and Thomas Gallagher provide guidance not only for improving communication with patients at their time of special need but also for the deeper and more pervasive cultural changes that our sick systems so sorely need. For example, we have learned that improving patient safety is less about implementing new practices than [44.223.42.120] Project MUSE (2024-03-29 06:53 GMT) FOREWORD ix about building the relationships that make implementation possible. Relationships , the authors wisely remind us, are guided and formed by our values. The core values they identify as essential to rebuilding relationships after a mishap—transparency, respect, accountability, continuity, and kindness—are in...