Patient Safety and Policy Reform
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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In October 2000, the Hastings Center initiated a two-year project to analyze theethical issues and values at stake in policy proposals on patient safety and thereduction of medical error. The catalyst for the project was the publication of theInstitute of Medicine (IOM) report To Err Is Human: Building a Safer Health System(Kohn, Corrigan, and Donaldson 2000) as well as reforms already underway...
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The Institute of Medicine (IOM) report To Err Is Human presented the mostcomprehensive set of public policy recommendations on medical error andpatient safety ever to have been proposed in the United States. Prompted bythree large insurance industry–sponsored studies on the frequency and severityof preventable adverse events, as well as by a host of media reports on harmful...
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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 yearsinto the operating theater where he had a routine prostatectomy from which henever recovered. Though he was in robust health apart from the tumor forwhich he was being treated, Elliot died some six hours after my children and I...
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This is a story about living with, not dying from, the consequences of medicalerror. It began in January 1990 when my husband suffered a devastating brain-stem injury in an auto accident on an icy highway in upstate New York. He wasdriving; 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. I emerged...
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A mistake in the profession of air traffic control can cause the death of hundredsof people at once. A mistake in the health care system can cause the death ofhundreds of people one person at a time. What is the difference? Hundreds ofpeople dying at once makes the front page of the newspaper as a disaster andrequires answers and changes to prevent the same thing from happening again....
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Tremendous attention has recently arisen regarding the social issue of medicalerror and its role in patient injury and quality of care. Traditionally, an individ-ually oriented “shame and blame” conception of quality has been the standard,with the tort system focused upon individual actor blame for harm, accredita-tion standards based upon individual entity compliance and punishment, and...
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The report of the Institute of Medicine (IOM) on the prevalence of medical errorhas engendered widespread attention to a human problem as old as medicineitself (Kohn, Corrigan, and Donaldson 2000). Physicians, patients, and thepublic have always recognized the fact of medical fallibility. Few physicians canclaim that they have never made an error of judgment or procedure. Few have...
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This chapter outlines the role of a hospital system in the way medical mistakesare handled. Much of the recent writing on medical error has either concen-trated on the individual clinician and his or her responsibilities in disclosure ofmedical error or, like the watershed Institute of Medicine (IOM) report To Err IsHuman (Kohn, Corrigan, and Donaldson 2000), has drawn attention to...
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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), isderived from Alexander Pope’s “Essay on Criticism” (1711): “To err is human; toforgive, divine” (l. 525). Given how familiar this proverb is in its entirety, it isstriking that the IOM report itself contains no reference to forgiveness, divine or...
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In its report To Err Is Human, the Institute of Medicine concluded that improve-ments in quality of care and patient safety depend on voluntary reporting sys-tems (Kohn, Corrigan, and Donaldson 2000). These systems were viewed asparticularly useful for identifying errors that occur too infrequently to bedetected by individual health care organizations examining their own data, and...
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Many Americans appear to believe that we are currently experiencing a plagueof medical errors. A decade ago, the Harvard Medical Practice Study reportedthat 4 percent of hospital patients suffered iatrogenic injuries, two-thirds ofwhich were due to medical error (Leape et al. 1991; Leape 1993). These andother error studies reported high rates of missed diagnoses, mistaken treat-...
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Reputation is not of enough value to sacrifice character for it.For over a century, opposition to malpractice litigation has been a litmus test formembership in the medical profession. Doctors hate malpractice suits. Theyhate them passionately and continuously. Being sued becomes a recurringnightmare for many physicians, and occasionally an obsession. Eliminating...
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Reducing injuries from medical error is a central focus of current health carepolicy and research. A traditional presumption of the law of civil liability, ortorts, is that charging a negligent person with the monetary consequences of hisor her lack of due care will cause others similarly situated to exercise greatercare in the future. This proposition, known to legal scholars as the “deterrence”...
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As an alternative to medical malpractice law for compensating patients whosustain injuries from health care, “no-fault” has a tragic public relationsproblem. Despite three decades of research painting a cautiously optimisticview of its merits, reasonably positive experiences with no-fault schemes inhealth care systems abroad, and attitudes among policymakers about the...
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In the wake of several prominent national stories and organizational reportsabout the pervasiveness and seriousness of errors in the nation’s health caresystem, 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...
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Aiello v. Muhlenberg R. Med. Ctr., 733 A.2d 433, 438 (N.J. 1999)Atlantic Coast Line Railroad Co. v. Whitney, 56 So. 937, 938 (Fla. 1911)Baer v. Regents of University of California, 972 P.2d 9, 13 (N.M. App. 1998)Burgos v. Giannakakos, 1998 Conn. Super. LEXIS 3328 (Conn. Super. 1998)Commission on Medical Discipline v. McDonnell, 467 A.2d 1072, 1075, 1079 ...
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Page Count: 288
Publication Year: 2004
Series Title: Hastings Center Studies in Ethics series