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Patient Safety and Policy Reform

Virginia A. Sharpe, Editor

Publication Year: 2004

According to a recent Institute of Medicine report, as many as 98,000 Americans die each year as a result of medical error -- a figure higher than deaths from automobile accidents, breast cancer, or AIDS. That astounding number of fatalities does not include the number of those serious mistakes that are grievous and damaging but not fatal. Who can forget the tragic case of 17-year-old Jésica Santillán, who died after receiving a heart-lung transplant with an incompatible blood type? What can be done about this? What should be done? How can patients and their families regain a sense of trust in the hospitals and clinicians that care for them? Where do we even begin the discussion?

Accountability brings the issue to the table in response to the demand for patient safety and increased accountability regarding medical errors. In an interdisciplinary approach, Virginia Sharpe draws together the insights of patients and families who have suffered harm, institutional leaders galvanized to reform by tragic events in their own hospitals, philosophers, historians, and legal theorists. Many errors can be traced to flaws in complex systems of health care delivery, not flaws in individual performance. How then should we structure responsibility for medical mistakes so that justice for the injured can be achieved alongside the collection of information that can improve systems and prevent future error? Bringing together authoritative voices of family members, health care providers, and scholars -- from such disciplines as medical history, economics, health policy, law, philosophy, and theology -- this book examines how conventional structures of accountability in law and medical structure (structures paradoxically at odds with justice and safety) should be replaced by more ethically informed federal, state, and institutional policies. Accountability calls for public policy that creates not only systems capable of openness concerning safety and error -- but policy that also delivers just compensation and honest and humane treatment to those patients and families who have suffered from harmful medical error.

Published by: Georgetown University Press


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pp. 1-5


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pp. viii-6

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pp. ix-xii

In October 2000, the Hastings Center initiated a two-year project to analyze the ethical issues and values at stake in policy proposals on patient safety and the reduction of medical error. The catalyst for the project was the publication of the Institute of Medicine (IOM) report To Err Is Human: Building a Safer Health System (Kohn, Corrigan, and Donaldson 2000) ...

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Introduction: Accountability and Justice in Patient Safety Reform

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pp. 1-26

The Institute of Medicine (IOM) report To Err Is Human presented the most comprehensive set of public policy recommendations on medical error and patient safety ever to have been proposed in the United States. Prompted by three large insurance industry–sponsored studies on the frequency and severity of preventable adverse events, ...

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1. Writing/Righting Wrong

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pp. 27-42

More than a decade has now passed since the sunny morning of February 11, 1991, when two orderlies arrived to wheel my husband of thirty-three years into the operating theater where he had a routine prostatectomy from which he never recovered. Though he was in robust health apart from the tumor for which he was being treated, ...

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2. Life but No Limb: The Aftermath of Medical Error

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pp. 43-48

This is a story about living with, not dying from, the consequences of medical error. It began in January 1990 when my husband suffered a devastating brainstem injury in an auto accident on an icy highway in upstate New York. He was driving; we were both wearing seatbelts. The car hit a patch of black ice, skidded, hit a guard rail, rolled over, and landed in a deep gully. ...

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3. In Memory of My Brother, Mike

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pp. 49-58

A mistake in the profession of air traffic control can cause the death of hundreds of people at once. A mistake in the health care system can cause the death of hundreds of people one person at a time. What is the difference? Hundreds of people dying at once makes the front page of the newspaper as a disaster and requires answers ...

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4. Error Disclosure for Quality Improvement: Authenticating a Team of Patients and Providers to Promote Patient Safety

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pp. 59-82

Tremendous attention has recently arisen regarding the social issue of medical error and its role in patient injury and quality of care. Traditionally, an individually oriented “shame and blame” conception of quality has been the standard, with the tort system focused upon individual actor blame for harm, ...

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5. Prevention of Medical Error: Where Professional and Organizational Ethics Meet

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pp. 83-98

The report of the Institute of Medicine (IOM) on the prevalence of medical error has engendered widespread attention to a human problem as old as medicine itself (Kohn, Corrigan, and Donaldson 2000). Physicians, patients, and the public have always recognized the fact of medical fallibility. ...

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6. Medical Mistakes and Institutional Culture

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pp. 99-118

This chapter outlines the role of a hospital system in the way medical mistakes are handled. Much of the recent writing on medical error has either concentrated on the individual clinician and his or her responsibilities in disclosure of medical error or, like the watershed Institute of Medicine (IOM) report To Err Is Human (Kohn, Corrigan, and Donaldson 2000), ...

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7. “Missing the Mark”: Medical Error, Forgiveness, and Justice

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pp. 119-134

The title of the Institute of Medicine’s report on medical error, To Err Is Human: Building a Safer Health System (Kohn, Corrigan, and Donaldson 2000), is derived from Alexander Pope’s “Essay on Criticism” (1711): “To err is human; to forgive, divine” (l. 525). Given how familiar this proverb is in its entirety, it is striking that the IOM report itself contains no reference to forgiveness, ...

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8. Is There an Obligation to Disclose Near-Misses in Medical Care?

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pp. 135-142

In its report To Err Is Human, the Institute of Medicine concluded that improvements in quality of care and patient safety depend on voluntary reporting systems (Kohn, Corrigan, and Donaldson 2000). These systems were viewed as particularly useful for identifying errors that occur too infrequently to be detected by individual health care organizations examining their own data, ...

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9. God, Science, and History: The Cultural Origins of Medical Error

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pp. 143-158

Many Americans appear to believe that we are currently experiencing a plague of medical errors. A decade ago, the Harvard Medical Practice Study reported that 4 percent of hospital patients suffered iatrogenic injuries, two-thirds of which were due to medical error (Leape et al. 1991; Leape 1993). ...

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10. Reputation, Malpractice Liability, and Medical Error

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pp. 159-184

For over a century, opposition to malpractice litigation has been a litmus test for membership in the medical profession. Doctors hate malpractice suits. They hate them passionately and continuously. Being sued becomes a recurring nightmare for many physicians, and occasionally an obsession. ...

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11. Ethical Misfits: Mediation and Medical Malpractice Litigation

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pp. 185-202

Reducing injuries from medical error is a central focus of current health care policy and research. A traditional presumption of the law of civil liability, or torts, is that charging a negligent person with the monetary consequences of his or her lack of due care will cause others similarly situated to exercise greater care in the future. ...

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12. On Selling “No-Fault”

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pp. 203-212

As an alternative to medical malpractice law for compensating patients who sustain injuries from health care, “no-fault” has a tragic public relations problem. Despite three decades of research painting a cautiously optimistic view of its merits, reasonably positive experiences with no-fault schemes in health care systems abroad, ...

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13. Medical Errors: Pinning the Blame versus Blaming the System

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pp. 213-232

In the wake of several prominent national stories and organizational reports about the pervasiveness and seriousness of errors in the nation’s health care system, providers are increasingly turning their attention to patient safety. Recently one major medical journal initiated a series of Quality Grand Rounds (QGR) that explores real clinical errors in considerable detail (Chassin and Becher 2002). ...

Cases Cited

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pp. 233-234


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pp. 235-262


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pp. 263-264


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pp. 265-276

E-ISBN-13: 9781589012301
E-ISBN-10: 1589012305

Page Count: 288
Publication Year: 2004