Accountability: Patient Safety and Policy Reform

Preface

P R E F A C E 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 ToErrIsHuman:BuildingaSaferHealthSystem (Kohn, Corrigan, and Donaldson 2000) as well as reforms already underway within institutions charged with oversight or provision of health care. To conduct this work, we assembled an interdisciplinary group of experts to help us make sense of the complex phenomenon of patient safety reform. Working group members brought their expertise as people who had suffered from devastating medical harms and as institutional leaders galvanized to reform by tragic events in their own health care institutions. They brought expertise as clinicians, chaplains, and risk managers working to deliver health care, to face its downsides, and to make it safer for current and future patients. They brought expertise in systems thinking from air traffic control and from the military. The project group also brought critical insight on the issue of patient safety from their work in medical history and sociology, economics, health care purchasing, health policy, law, philosophy, and religion. I am grateful for all of the time and intelligence that the group brought to the project and am pleased to bring their expertise together in this volume. The introduction lays out the rationale for the project, the broad topics of the volume—disclosure, reporting, compensation, and error prevention—and notes in some detail the ways in which these topics are addressed by each author. After a brief overview of the IOM report, the introduction identifies the ethical values and issues at stake in proposed reforms, placing particular emphasis on the need for policymakers to grapple simultaneously with the demands of accountability, justice, and safety. Chapters 1 through 3, by Sandra M. Gilbert, Carol Levine, and Roxanne Goeltz, respectively, are powerful narratives about the losses that they and their loved ones have suffered not simply as a result of medical error, but also as a result of the inhumanities of the health care system. Sandra Gilbert is a poet and literary critic whose husband died as a result of still-unexplained causes following a routine prostatectomy. She describes the multiple ways in which she and others who seek redress for catastrophic medical events are silenced in their ix FM sharpe ppi-xii 08/05/2004 16:27 Page ix attempts to right the wrong that has occurred. Carol Levine writes about a medical error that resulted in her husband’s loss of his arm following a devastating brain-stem injury in an automobile accident. Levine, director of the Project on Families and Health Care at the United Hospital Fund of New York, places her experience in the broader context of health care financing and delivery, describing what it means for patients and their family-caregivers to live with the consequences of medical error in a system ill-prepared to support long-term care for the injured. Roxanne Goeltz provides a searing account of her brother’s death as the result of omissions in his hospital care. This experience, as well as her own postsurgical pulmonary embolism in an understaffed hospital unit, has led Goeltz to become a pioneer in patient safety, bringing the insights of her field, air traffic control, to health care delivery. As a safety advocate, Goeltz recommends that during hospital care, patients have a friend or family member with them twenty-four hours a day, seven days a week. Chapters 4 through 8, by Bryan A. Liang, Edmund D. Pellegrino, Carol Bayley, Nancy Berlinger, and Albert W. Wu, focus on the institutional, cultural, and moral contexts in which errors occur and are revealed or concealed. Bryan Liang describes how the traditional response of “shame and blame”—that emphasizes individual culpability for error—is counterproductive both in improving institutional safety and in delivering justice to harmed parties. Liang argues that shifting our focus from individual culpability to system failures will allow for all members of a health care team—including patients—to contribute to the safety enterprise. Edmund Pellegrino, by contrast, argues that a systems approach cannot and should not replace individual accountability for error and its aftermath. He calls for the creation of institutional cultures that foster rather than discourage individual virtue both in preventing and in responding to error. Carol Bayley, vice president for ethics and justice education at Catholic Healthcare...