Top 10 issues in hospital medicine for 2008, issue 2: patient safety and the culture of blame

Just as the quality movement has led to a culture of shame, the safety movement has exacerbated a culture of blame. That’s pretty ironic given that the seminal document of the patient safety movement, IOM’s To Err is Human, viewed the culture of blame as counterproductive and sought to mitigate it. This statement is from the executive summary of the book:

The focus must shift from blaming individuals for past errors to a focus on preventing future errors by designing safety into the system. This does not mean that individuals can be careless. People must still be vigilant and held responsible for their actions. But when an error occurs, blaming an individual does little to make the system safer and prevent someone else from committing the same error.

Why did this unfortunate and unintended consequence come about? It’s an example of what happens when a nuanced and highly complex issue gets thrown into the arena of unenlightened and uninformed public debate. Policy wonks distort it. Media spin it egregiously. Trial lawyers take notice.

We’ve seen the consequences this year. CMS’s ill-conceived and manifestly unfair never events policy went into effect, redefining many unavoidable events in hospitals as errors. With such redefinition comes a strong implication of widespread institutional and individual blame. The idea of patient harm as a “never event” has also spawned a new legal principle in which any patient harm is prima facie evidence of negligence, leading to more law suits and a shift in the burden of proof. Ready for the next malpractice crisis?