Saturday, December 05, 2009

Patient safety and blame: from the literature

In a December 2 post on this topic I argued that the patient safety movement has made little progress since the Institute of Medicine report due to a prevailing culture of blame in medicine, one which existed for decades but was exacerbated by the language of the report, which inappropriately defined many adverse patient events as medical errors. Since writing that post I have reviewed some of the relevant literature.

A JAMA article published just a year and a half after the release of the IOM report presciently warned that the prevailing culture of blame was on a collision course with the patient safety agenda. The authors noted:

Leading patient safety proposals promote the design and implementation of error prevention strategies that target systems used to deliver care and eschew individual blame. They also call for candor among practitioners about the causes and consequences of medical injury. Both goals collide with fundamental tenets of the medical malpractice system.

...Unfortunately, because access to compensation for medical injury in our health care system hinges on blame and individual provider fault, the patient safety reforms spurred by the IOM report are on a collision course with the medical malpractice system. In the short term, that collision is likely to stymie much-needed attempts to make US hospitals safer.

They were advocating a no-fault compensation system. Indeed, a common thread in some of the articles I reviewed was that in order for real progress to be made in the field of patient safety we need a no-fault system. No-fault compensation would address patient harm without an emphasis on individual blame. This would eliminate much of the finger-pointing and peel back layers of defensive posturing, which undermine the transparency so necessary to address patient safety effectively.

A no blame culture would not remove accountability. The JAMA authors cited examples from other countries and explained how regulatory agencies and policies of individual health systems could maintain accountability under a no-fault system.

A no-fault system would encourage compensation and examination of patient injuries as adverse events without regard to blame. The IOM report had the opposite effect. The unfortunate spin of the report (based on misinterpretation of research findings and criticized by one of the original researchers) led to widespread media hype which ultimately provided much of the impetus for the Medicare never-events policy which is now on a path to defining most adverse events as blameworthy. This is leading to a new tort standard which shifts the burden of proof and finds fault in many non-preventable injuries.

Careless use of words like “error”, as was done in the IOM report, is a major factor in producing a culture of blame. In reporting Canada's struggle to promote a culture of transparency this CMAJ news piece describes the concern for the use of language:

The Canadian Medical Protective Association, which insures doctors in Canada, is also playing a key role in developing the national guidelines. For its part, the association "and doctors in general do not like [the terms] harm, or medical error. We like the term adverse events....”

Alberta has arguably gone farthest down the road of working through issues around disclosure, in part because of some highly publicized patient deaths caused by "a huge series of errors in central pharmacy," Flemons notes, adding that greater disclosure is necessary to maintain public trust and confidence. Alberta opted to use the term harm, adopting a definition developed by the College of Physicians and Surgeons of Ontario. The term harm "drives the lawyers crazy — that is where the struggle has been — since they want to make the terms as narrow as possible," Flemons says. "But we think that is the best patient-focused word. ... It is about if the patient suffers harm, and that may not involve medical error. Our policy is to disclose all harm."

A follow up report in CMAJ noted (my italics):

Even the use of some words (error, blame and harm) became a lightning rod when one of the Canadian Patient Safety Institute's multistakeholder working groups hammered out recently published national disclosure guidelines (CMAJ 2007;177[11]:1342-3). The guidelines stated purposes are to promote "timely, truthful and transparent disclosure," assist patients in accessing further health care and personal supports and, at the same time, discourage attribution of blame. Yet, notably, a lengthy explanation of why the word "error" should be avoided takes a prominent place in the published document.

This survey published in Health Affairs found that institutions were less likely to disclose when blame was attached.

Another survey, published in the Archives of Internal Medicine, found that physicians are more comfortable avoiding reference to error in the disclosure of adverse events.

If the IOM report and the never-events policy were not enough, note that the latest draft of the House health care reform bill contains an anti-tort reform provision which incentivizes states to avoid caps on attorney fees and damages. (H/T to Aggravated DocSurg. Go and read the document here).

A blame free culture and no-fault compensation would allow a quantum leap in patient safety. But we're going in the wrong direction. Although the discussion of patient safety has been elevated and some important systems are coming into place, progress over the next decade is likely to be modest.


Michael Kirsch, M.D. said...

RW, your no-fault idea, which has merit, is a political non-starter. The status quo of the medical malpractice system is entrenched and supported by important stakeholders. Of course, the system does not serve the public interest. Beyond torturing the medical professions, it incinerates tens of billions of dollars in legal costs and in defensive medicine. Most patients who are injured negligently are not captured by the system. Finally, it discourages the medical profession from admitting error so we can improve our performance. I am glad that I stumbled across your fine blog. You may wish to visit for more perspective on medical malpractice and medical quality,

R. W. Donnell said...

Yes, it is a non-starter, as is any hope for the type of blame free culture necessary for the transparency needed to address patient safety head on (without all the defensiveness, administrative posturing, creative charting, etc). In my opinion this was an unintended consequence of the IOM report. Now the defensive culture is all the more entrenched---defined administratively and embedded in our largest entitlement program. That's why I'm not optimistic about the patient safety movement.