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C H A P T E R 1 3 Medical Errors: Pinning the Blame versus Blaming the System E . H A A V I M O R R E I M Introduction 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). The inaugural QGR featured a case in which two patients had similar names. Through a series of errors, the person who should have been sent for cerebral angiography was mistakenly sent for the invasive cardiac electrophysiology study that the other patient should have received. The error was discovered approximately one hour into the procedure, which was then aborted. Two authors were invited to review the numerous individual mistakes that together created the problem; their discussion emphasizes the systemic problems that made this mix-up possible and the kinds of system-oriented improvements that could make this kind of error less likely in the future. For instance, the authors point out how people who work in health care centers are accustomed to poor communication and a lack of teamwork. Hence, when the patient said she hadn’t been told she was to receive the electrophysiology study, the nurse did not consider this to be a reason to stop transporting her for the test, since it is not unusual for patients to know rather little about their care. Similarly, when a resident was surprised to see that his patient had been taken for this procedure, he assumed that the attending physician had simply ordered the test and failed to inform him about it—again highlighting the “culture of low expectations” and poor communication endemic in many medical centers. The authors then offer proposals for avoiding similar errors in the future, such as to institute standardized protocols for verifying patient identity. And they discourage punishment. “No single error caused this adverse event; there is no 213 c13 sharpe pp213-232 08/05/2004 16:59 Page 213 reason to expect that punishing individuals would reduce the likelihood of recurrence” (Chassin and Becher 2002, 831). In this and other discussions about reducing errors and maximizing patient safety, a certain line of reasoning has become prominent—call it the “common view” or the “standard analysis.” Errors are caused by systems, it is said, and rarely if ever by individual people.1 Accordingly, if we want to prevent errors we must focus on systems rather than individuals, to discover the structures and procedures that make problems likely. That sort of investigation involves finding out how, when, and why errors occur—which requires abundant and specific information from the people actually involved in those errors. However, people are unlikely to report freely about adverse incidents and their personal roles in them unless the information and those who provide it are protected. And that protection, in turn, requires shielding those who report from those who might wish to punish them. At this point a dilemma is alleged to arise. On the one hand, moral justice traditionally requires blame and sometimes also punishment for those who carelessly or culpably harm someone. Injured individuals are therefore entitled to receive information about the errors that befell them, and to expect compensation for errors that wrongly befell them at providers’ hands, whether individual or institutional providers. On this view, if error reports could be used to promote accountability for those who are blameworthy, then injured individuals should have access to this information. On the other hand, the greater good may require minimizing the impetus toward blame, even where someone has been careless, in order to promote reporting, improve systems, enhance health care safety and thereby harm fewer people overall. If free reporting of errors requires a blame-free atmosphere, then perhaps reports about errors should not be shared with the very patients and families who were harmed. In sum, justice for those who are injured appears to be traded off for the greater good of future patients. The dilemma is familiar from the peer review setting where, on the one hand, plaintiffs’ attorneys have complained that hospitals’ peer review reports should not be concealed from injured patients who may be entitled to compensation, whereas, on the other hand, hospitals insist that quality improvement requires confidentiality in at least this setting. Many...


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