Accountability: Patient Safety and Policy Reform

Virginia A. Sharpe Editor
Copyright Date: 2004
Pages: 288
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  • Book Info
    Book Description:

    According to a recent Institute of Medicine report, as many as 98,000 Americans die each year as a result of medical error-a figure higher than deaths from automobile accidents, breast cancer, or AIDS. That astounding number of fatalities does not include the number of those serious mistakes that are grievous and damaging but not fatal. Who can forget the tragic case of 17-year-old Jésica Santillán, who died after receiving a heart-lung transplant with an incompatible blood type? What can be done about this? What should be done? How can patients and their families regain a sense of trust in the hospitals and clinicians that care for them? Where do we even begin the discussion? Accountability brings the issue to the table in response to the demand for patient safety and increased accountability regarding medical errors. In an interdisciplinary approach, Virginia Sharpe draws together the insights of patients and families who have suffered harm, institutional leaders galvanized to reform by tragic events in their own hospitals, philosophers, historians, and legal theorists. Many errors can be traced to flaws in complex systems of health care delivery, not flaws in individual performance. How then should we structure responsibility for medical mistakes so that justice for the injured can be achieved alongside the collection of information that can improve systems and prevent future error? Bringing together authoritative voices of family members, health care providers, and scholars-from such disciplines as medical history, economics, health policy, law, philosophy, and theology-this book examines how conventional structures of accountability in law and medical structure (structures paradoxically at odds with justice and safety) should be replaced by more ethically informed federal, state, and institutional policies. Accountability calls for public policy that creates not only systems capable of openness concerning safety and error-but policy that also delivers just compensation and honest and humane treatment to those patients and families who have suffered from harmful medical error.

    eISBN: 978-1-58901-230-1
    Subjects: Health Sciences

Table of Contents

  1. Front Matter
    (pp. ii-vi)
  2. Table of Contents
    (pp. vii-vii)
    (pp. ix-xii)
  4. INTRODUCTION: Accountability and Justice in Patient Safety Reform
    (pp. 1-26)

    The Institute of Medicine (IOM) report To Err Is Human presented the most comprehensive set of public policy recommendations on medical error and patient safety ever to have been proposed in the United States. Prompted by three large insurance industry–sponsored studies on the frequency and severity of preventable adverse events, as well as by a host of media reports on harmful medical errors, the report offered an array of proposals to address at the policy level what is being identified as a new “vital statistic”: that as many as 98,000 Americans die each year as a result of medical...

  5. CHAPTER 1 Writing/Righting Wrong
    (pp. 27-41)

    More than a decade has now passed since the sunny morning of February 11, 1991, when two orderlies arrived to wheel my husband of thirty-three years into the operating theater where he had a routine prostatectomy from which he never recovered. Though he was in robust health apart from the tumor for which he was being treated, Elliot died some six hours after my children and I were told that his surgeon had successfully removed the malignancy. But to this very moment, no one from the hospital has explained to us how or why he died.

    “Dad’s had a heart...

  6. CHAPTER 2 Life but No Limb: The Aftermath of Medical Error
    (pp. 43-48)

    This is a story about living with, not dying from, the consequences of medical error. It began in January 1990 when my husband suffered a devastating brainstem injury in an auto accident on an icy highway in upstate New York. He was driving; we were both wearing seatbelts. The car hit a patch of black ice, skidded, hit a guard rail, rolled over, and landed in a deep gully. I emerged shaken but unharmed, but my husband was unconscious and unresponsive. In that brief moment our lives changed forever.

    I have written about my experiences as my husband’s caregiver, but...

  7. CHAPTER 3 In Memory of My Brother, Mike
    (pp. 49-57)

    A mistake in the profession of air traffic control can cause the death of hundreds of people at once. A mistake in the health care system can cause the death of hundreds of people one person at a time. What is the difference? Hundreds of people dying at once makes the front page of the newspaper as a disaster and requires answers and changes to prevent the same thing from happening again. But hundreds of people dying one person at a time does not make the nightly news—yet it continues to happen in a profession that has always been...

  8. CHAPTER 4 Error Disclosure for Quality Improvement: Authenticating a Team of Patients and Providers to Promote Patient Safety
    (pp. 59-82)

    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,...

  9. CHAPTER 5 Prevention of Medical Error: Where Professional and Organizational Ethics Meet
    (pp. 83-98)

    The report of the Institute of Medicine (IOM) on the prevalence of medical error has engendered widespread attention to a human problem as old as medicine itself (Kohn, Corrigan, and Donaldson 2000). Physicians, patients, and the public have always recognized the fact of medical fallibility. Few physicians can claim that they have never made an error of judgment or procedure. Few have not observed the errors of their colleagues. All are cognizant that the claim of the profession to police itself has never been responsibly actualized. To date, no comprehensive program of error prevention has ever been actualized. It is...

  10. CHAPTER 6 Medical Mistakes and Institutional Culture
    (pp. 99-117)

    This chapter outlines the role of a hospital system in the way medical mistakes are handled. Much of the recent writing on medical error has either concentrated on the individual clinician and his or her responsibilities in disclosure of medical error or, like the watershed Institute of Medicine (IOM) report To Err Is Human (Kohn, Corrigan, and Donaldson 2000), has drawn attention to industry-wide problems and their potential solutions. Here I look at the nexus of these domains, at the ethical responsibilities and motivations of particular health care institutions.

    The first section of the chapter situates this work within a...

  11. CHAPTER 7 “Missing the Mark”: Medical Error, Forgiveness, and Justice
    (pp. 119-134)

    The title of the Institute of Medicine’s report on medical error, To Err Is Human: Building a Safer Health System (Kohn, Corrigan, and Donaldson 2000), is derived from Alexander Pope’s “Essay on Criticism” (1711): “To err is human; to forgive, divine” (l. 525). Given how familiar this proverb is in its entirety, it is striking that the IOM report itself contains no reference to forgiveness, divine or otherwise, in its treatment of medical error, even as its title hints at a fundamental relationship between error and forgiveness. In this chapter, I provide an overview of the close links between the...

  12. CHAPTER 8 Is There an Obligation to Disclose Near-Misses in Medical Care?
    (pp. 135-142)

    In its report To Err Is Human, the Institute of Medicine concluded that improvements in quality of care and patient safety depend on voluntary reporting systems (Kohn, Corrigan, and Donaldson 2000). These systems were viewed as particularly useful for identifying errors that occur too infrequently to be detected by individual health care organizations examining their own data, and patterns of errors that reflect systemic issues. Some of these errors are “near-misses” that do not cause harm to the patient. Reporting near-misses offers several advantages for achieving improvements in quality and patient safety: they have not resulted in patient harm and...

  13. CHAPTER 9 God, Science, and History: The Cultural Origins of Medical Error
    (pp. 143-158)

    Many Americans appear to believe that we are currently experiencing a plague of medical errors. A decade ago, the Harvard Medical Practice Study reported that 4 percent of hospital patients suffered iatrogenic injuries, two-thirds of which were due to medical error (Leape et al. 1991; Leape 1993). These and other error studies reported high rates of missed diagnoses, mistaken treatments, medication errors, and a wide range of other mistakes in patient care (Leape 1994; Bedell et al. 1991; Shimmel 1964). More recently, of course, the Institute of Medicine (IOM) report To Err Is Human: Building a Safer Health Care System...

  14. CHAPTER 10 Reputation, Malpractice Liability, and Medical Error
    (pp. 159-183)

    For over a century, opposition to malpractice litigation has been a litmus test for membership in the medical profession. Doctors hate malpractice suits. They hate them passionately and continuously. Being sued becomes a recurring nightmare for many physicians, and occasionally an obsession. Eliminating malpractice suits takes precedence over every other political objective—whether public-interested or self-serving—for the American Medical Association and state medical societies. No contradictory belief, however well-reasoned, empirically based, or sincerely held, succeeds in crowding out antipathy toward malpractice from physicians’ minds. Not the large number of patients who die unnecessarily each year from medical errors; not...

  15. CHAPTER 11 Ethical Misfits: Mediation and Medical Malpractice Litigation
    (pp. 185-201)

    Reducing injuries from medical error is a central focus of current health care policy and research. A traditional presumption of the law of civil liability, or torts, is that charging a negligent person with the monetary consequences of his or her lack of due care will cause others similarly situated to exercise greater care in the future. This proposition, known to legal scholars as the “deterrence” function of torts, would suggest that a sound system of civil liability can make a positive contribution to the quest for patient safety.

    Quite to the contrary, fault-based tort law has recently been subjected...

  16. CHAPTER 12 On Selling “No-Fault”
    (pp. 203-212)

    As an alternative to medical malpractice law for compensating patients who sustain injuries from health care, “no-fault” has a tragic public relations problem. Despite three decades of research painting a cautiously optimistic view of its merits, reasonably positive experiences with no-fault schemes in health care systems abroad, and attitudes among policymakers about the existing malpractice system that fluctuate between tolerance and panic, no-fault continues to live in the policy doghouse. It remains the darling of a small group of medico-legal researchers and is without champions among the most powerful stakeholders in American health care.¹

    Is no-fault’s pariah status deserved? Should...

  17. CHAPTER 13 Medical Errors: Pinning the Blame versus Blaming the System
    (pp. 213-232)

    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...

    (pp. 233-234)
    (pp. 235-261)
    (pp. 263-263)
  21. INDEX
    (pp. 265-276)