restricted access 4. Error Disclosure for Quality Improvement: Authenticating a Team of Patients and Providers to Promote Patient Safety
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C H A P T E R 4 Error Disclosure for Quality Improvement: Authenticating a Team of Patients and Providers to Promote Patient Safety B R Y A N A . L I A N G Introduction 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, accreditation standards based upon individual entity compliance and punishment, and medical culture reliance on an individual provider ethic of perfection (Hupert et al. 1996; Leape 1994; Liang 2001a; Liang and Storti 2000). Despite these mechanisms, over the past five decades, medical error and patient injury continue to plague the health care delivery system, and, indeed, this shame orientation and blame ideal have created barriers to practice change, quality improvement efforts, and improved health care (Davidoff 2002; Shekelle 2002). Such poor results have provided a significant impetus for reevaluating these traditional methods. This reevaluation has resulted in the emergence of an understanding that the traditional methods focused upon a particular individual making a specific error are ineffective in improving performance within highly complex systems such as medicine (Leape 1994; Reason 1990). With the advent of new understandings and recognitions regarding the systems nature of error, and the success of other similarly complex industries such as aviation and nuclear power in using these lessons to reduce the incidence of error and to improve efficiency and efficacy, there is room for optimism that similar results could attend in health care (Liang 2001a). 59 c04 sharpe pp 59-82 08/05/2004 16:45 Page 59 Unfortunately, current legal and medical cultures continue to maintain the individually oriented perspective regarding error and injury (Liang 1999, 2001a). Further, accreditation organizations and others within the professions and the public, using the patient safety and medical error platform, now call for simple disclosure of errors to patients without reference to the systems nature of error, how these disclosures practically affect care, or how these disclosures could promote safety and quality;1 indeed, such reactionary calls for indiscriminate disclosure reflect the shame and blame ethic. Moreover, they result in only ex post unidirectional information flow and do not authenticate the important role of partnership between patients, their families, and providers in medical care. Indeed, such mandates do not empower patients and/or families to directly impact care as part of the delivery team and to be another set of eyes to identify errors and reduce their consequences. Thus, at present, although there has been a recognition of the fundamental basis of error—systems—the medical and legal communities as well as the general public have yet to embrace systems concepts to improve safety in health care delivery (Liang 2002a). Further, many who call for full disclosure of errors in the name of safety use patient safety jargon to simply promote the individually oriented, status quo “shame and blame” approach.2 Unfortunately, such perspectives drive the knowledge and observations of error underground, fating others in the future to be subject to the same systems infrastructures and injuries that could have been corrected had they been discussed and addressed (Leape 1994). Instead, following the successful model from other industries, to address the nature, incidence, and effect of error on safety, a systems approach must be undertaken that allows for all members of the system team to contribute to the safety enterprise (Liang 2000d, 2002a). In health care, this team includes providers and patients. By integrating providers and patients, each with rights and responsibilities, and by promoting communication between the two as equal partners, safety in health care can be advanced and a greater therapeutic relationship can be attained. However, such a partnership and relationship will require not only a recognition of the weaknesses that derive from current medical and legal systems, but also an adherence to an ideal of mutual respect that is often stated but little implemented (Liang 2002a). Such an effort can begin with a system of medical error disclosure that takes into account current perspectives and educates providers and patients regarding medical error, patient injury, and systems processes. Further, in contrast to calls for disclosure that presume patients to have only rights, and providers to have only obligations, such an effort should be designed to indicate the essential role of both in promoting safety. 60 L I A N G c04 sharpe pp 59...