Different opinions on responsibility in healthcare system
The science and technology are evolving incredibly fast. Despite that, the healthcare system has a lot of insufficiencies and medical failures happen consistently. In recent years the focus has been on increasing the quality of healthcare. According to statistics from national studies from different European countries, 8 to 10 % of mistakes are being caused by the human factor. In this text I discuss the most fundamental concepts of individual and collective guilt and point out that in healthcare system are individuals often part of a team and it is not possible to determine unambiguously the individual responsibility. In spite of this the dominant culture of guilt tends to penalize the individual. In my opinion, the urgency of this topic in Slovakia and The Czech Republic is emphasized by the increasing number of cases of failure which are being discussed in the media. Therefore, I point out even possible impact of media and the guilt culture on the medical professional who fail and simultaneously I conclude that blaming the individual does not make the system safer. Our focus should rather be centred on showing that an individual can be incautious. However, when the mistake happens we should appeal to improving the system and a prevention of this type of mistakes. Only this way we can change the culture of guilt to a culture of safety and improve the healthcare.
(Fulltext in Slovak)
Keywordshealthcare system, responsibility, culture of guilt, media
ASQ (2007). Nurse Charged With Felony in Fatal Medical Error. Retrieved from http://asq.org/…displaySetup?….
Aveling, E., Parker, M., & Dixon-Woods, M. (2016). What is the role of individual accountability in patient safety ? A multi-site ethnographic study. Sociology of Health & Illness, 38(2), 216–232. https://doi.org/…7-9566.12370
Ballantyne, T. (2002). Peers support sieged pilots: Taipei accused of glossing over airport deficiencies. Orient Aviation, 6, 20–21.
Bendová, J., & Vaverková, I. (2012). Bezpečnosť pacienta v primárnej starostlivosti na Slovensku. Všeobecné lekárstvo, 9(1), 32–33.
Bell, S. K., Delbanco, T., & Anderson-shaw, L. (2011). Accountability for medical error moving beyond blame to advocacy. CHEST, 140(2), 519–526. https://doi.org/…hest.10-2533
Bosk, C. L. (2003). Forgive and Remember: Managing Medical Failure. Chicago, IL: University of Chicago Press.
Cullen, C. J., Bates, D. W., & Small, S. D. (1995). The incident reporting system does not detect adverse drug events: a problem for quality improvement. Joint Commission Journal on Quality and Patient Safety, 12, 541–52. https://doi.org/…6/S1070-3241(16)30180–8
Dekker, S. W. A. (2003). When human error becomes a crime. Human Factors and Aerospace Safety, 3(1), 83–92. Retrieved from http://sidneydekker.com/…meDekker.pdf
Dekker, S. (2012). Just culture: Balancing safety and accountability. CRC Press: Ashgate Publishing.
Donabedian, A. (1996). Evaluating the quality of medical care. Milbank Quarterly, 83(4), 691–-729. https://doi.org/10.2307/3348969
Edwin, A. K. (2009). Non-disclosure of medical errors an egregious violation of ethical principles. Ghana Medical Journal, 43(1), 34–39. Retrieved from https://www.ncbi.nlm.nih.gov/…/PMC2709172/
Gallagher, T. H. & Levinson, W. (2004). The Wrong Shot: Error Disclosure (AHRQ). Retrieved from http://www.ihi.org/…closure.aspx.
Genovese, U., Sordo, S. D., Pravettoni, G., Akulin, I., Zoja, R., & Casali, M. (2017). A new paradigm on health care accountability to improve the quality of the system: four parameters to achieve individual and collective accountability. Journal of Global Health, 7(1), 6–9. https://doi.org/…gh.07.010301
Gurňáková, J. (2017). Mýliť sa je nebezpečné alebo potrebuje medicína psychológiu? In M. Blatný, M. Jelínek, P. Květon, D. Vobořil (Eds), Sociální procesy a osobnost 2017: Sborník příspěvků. Brno: Masarykova univerzita.
Gorovitz, S., & MacIntyre, A. (1975). Toward a theory of medical fallibility. Philosophy, 5(6), 13–23. https://doi.org/10.2307/3560992
Hilfiker, D. (1984). Facing Our Mistakes. The New England Journal of Medicine, 310(2), 188–222. https://doi.org/…401123100211
Hinyard, L. J., & Kreuter, M. W. (2007). Using narrative communication as a tool for health behavior change: A conceptual, theoretical, and empirical overview. Health Education & Behavior, 34(5), 777–792. https://doi.org/…198106291963
Holden, R. J., & Karsh, B. (2007). A review of medical error reporting system design consideration and a proposed cross-level systems research framework. Human Factors, 49(2), 257–276. https://doi.org/…72007X312487
Jeffe, D. B., Dunagan, W. C., & Garbutt, J. et al. (2004). Using focus groups to understand physicians’ and nurses’ perspectives on error reporting in hospitals. Joint Commission Journal on Quality and Safety, 30(9), 471–479. https://doi.org/…6/S1549-3741(04)30055–9
Jensen, C. B. (2007). Sociology, systems and (patient) safety: knowledge translations in healthcare policy. Sociology of Health & Illness, 30(2), 309–324. https://doi.org/…2007.01035.x
Kohn, L. T., Corrigan, J. M. & Donaldson, M. S. (2000). To Err is Human: Building a Safer Healthcare System. Washington D.C.: National Academy Press.
Lawton, R., & Parker, D. (2002). Barriers to incident reporting in a healthcare system. Quality and Safety in Health Care, 11, 15–19. http://dx.doi.org/…/qhc.11.1.15
Leape, L. L., Kabcenell, A. I., Gandhi, T. K., Carver, P., Nolan, T.W., & Berwick, D. M. (2000). Reducing adverse drug events: Lessons from a breakthrough series collaborative. Joint Commission Journal on Quality and Patient Safety, 26(6), 321–331. https://doi.org/…6/S1070-3241(00)26026–4
Lerner, J. S., & Tetlock, P. E. (1999). Accounting for the effects of accountability. Psychological Bulletin, 125(2), 255–275. http://dx.doi.org/…09.125.2.255
Lewis, H. D. (1984). Collective responsibility. Philosophy, 23(84), 3–18. https://doi.org/…819100065943 Marx, D. (2001). Patient Safety and the “Just Culture”: A Primer for Health Care Executives. New York: Columbia University.
Meadows, S., Baker, K., & Butler, J. (2005). The incident decision tree: guidelines for action following patient safety incidents. Advances in Patient Safety, 4, 387–400. Retrieved from https://www.ncbi.nlm.nih.gov/…NBK20586.pdf
Monk, G., Sinclair, S., & Nelson, M. (2016). Exploring healthcare professionals’ use of narrative mediation approaches to address disclosure and apology in the aftermath of medical errors. Narrative and Conflict: Explorations of Theory and Practise, 3(1), 24–43. https://doi.org/…3.1.2016.531
Narveson, J. A. N. (2002). Collective responsibility. The Journal of Ethics, 6(1), 179–198. https://doi.org/…015823716891
Oyebode, F. (2006). Clinical errors and medical negligence. Advance in Psychiatric Treatment, 12, 221–227. https://doi.org/…59/000346296
Perrow, Ch. (1999). Normal accidents: Living with high-risk technologies. Princeton, N.J: Princeton University Press. Reason, J. (1990). Human error. New York, NY, US: Cambridge University Press.
Reason, J. T. (1997). Managing the risks of organizational accidents. Aldershot, Hants, England: Ashgate.
Nunes, R., Brandao, C., & Rego, G. (2011). Public accountability and sunshine healthcare regulation. Health Care Analysis, 19(4), 352–364. Retrieved form https://link.springer.com/…8-010-0156-6
Robinson, A. R., Hohmann, K. B., Rifkin, J. I., Topp, D., Gilroy, C. M., Pickard, J. A., & Anderson, R. J. (2002). Physician and public opinions on quality of health care and the problem of medical errors. JAMA Internal Medicine, 162(19), 2186–2190. https://doi.org/….162.19.2186
Sagan, S. (1993). The Limits of Safety: Organizations, accidents and nuclear weapons. Princeton, NJ: Princeton University Press.
Starfield, B. (2000). Is US health really the best in the world? JAMA, 284(4), 483–485. https://doi.org/…ma.284.4.483
Stoyanova, R. G., Rayacheva, R. D., & Dimova, R. T. (2012). Economic aspects of medical errors. Folia Medica, 54(1), 58–64. https://doi.org/…3-011-0079-5
Suresh, G., Horbar, J. D., Plsek, P., Gray, J., Edwards, W. H., Shiono, P. H., & Ursprung, R. (2004). Voluntary anonymous reporting of medical errors for neonatal intensive care. Pediatrics, 113(6), 1609–1618. https://doi.org/…s.113.6.1609
Thompson, D. F. (1980). Moral responsibility of public officials: The problem of many hands. The American Political Science Review, 74(4), 905–916. https://doi.org/10.2307/1954312
Wachter, R. M. (2013). Personal accountability in healthcare: Searching for the right balance. BMJ Quality & Safety, 22(2), 176–182. http://dx.doi.org/…-2012-001227
Wachter, R. M. & Pronovost, P. J. (2010). Balancing ‘no blame’ with accountability in patient safety. New England Journal of Medicine, 361(14), 1401–1406. http://dx.doi.org/…EJMsb0903885
Waldman, J. D., & Smith, H. L. (2012). Strategic planning to reduce medical errors: Part I-Diagnosis. The Journal of Medical Practice Managment, 27(5), 260–262.
Warrier, S., & Mcgillen, B. (2011). The evolution of quality improvement. Medicine and Health, Rhode Island, 94, 211–212. Retrieved from http://www.rimed.org/…1-07-211.pdf
Weber, M. (1978). Economy and Society. Berkeley: University of California Press.
Weingart, S. N., Ship, A. N., & Aronson, M. D. (2000). Confidential clinician-reported surveillance of adverse events among medical inpatients. Journal of General Internal Medicine, 15, 470–477.
Wilkinson, S. (1994). The November Oscar incident. Air and Space, February–March. WHO. (2017). Data and statistics. Retrieved from http://www.euro.who.int/…d-statistics