Canada wasn’t the first country to examine the rate of adverse events in its hospitals, but it did learn a thing or two from those already on the road to patient safety. From the outset of the Canadian Adverse Events Study, its funding bodies and researchers worked with health care stakeholders to enable them to prepare responses and launch various safety initiatives and projects. By the time the study results were published in 2004, the federal and provincial governments, professional, regulatory, and health care organizations had already established a direction for patient safety.
Much of their efforts focused on gathering more and better hospital data by encouraging and promoting a ‘culture of no blame’ among health care providers. Based on the premise that most medical errors are caused by system failures, it forgoes placing individual blame in favour of reporting and sharing information on adverse events. It operates on the belief that without such a culture errors will go unreported and system improvements left unmade. The lack of individual responsibility and accountability within this ‘culture of no blame’ meant that some patients did not embrace it as readily as other health care stakeholders.
Over the years, public demands for greater accountability in health care have led a number of provinces to enact legislation for reporting, disclosing and apologizing for adverse events. However, variations in legislation coupled with differing definitions and hospital policies can lead to selective reporting and disclosure. Even more discouraging to patients and their families is the legal protection afforded to information obtained through quality reviews and investigations. Many medical errors still go unreported and are only brought to light by patients filing formal complaints or approaching the media. In many of these cases there is even a tendency to try and shift blame towards the patient.
Now the patient safety movement is embracing a new ‘just culture’ proposing to combine the systemic error approach of a blameless culture with some individual accountability tied to reckless behaviour.
Do these cultures reduce the incidence of medical errors or do they merely result in blame-shifting and therefore liability-shifting between health care providers and the systems in which they work?
What happens when individual accountability is not addressed? Some of the more highly publicized cases involving patient harm include Ontario gynaecologists Dr. Errol Wai-Ping and Dr. Richard Austin, both of whom were allowed to continue practicing despite a number of formal complaints filed against them over a period of years. Hundreds of women came forward with their stories following a series of investigative reports by The Toronto Star.
What happens when system failures are not addressed? A letter written by Dr. Paul Parks of the Alberta Medical Association to the provincial Minister of Health recently appeared in the Calgary Herald. It expresses concern over the ongoing system failures causing a crisis in emergency medicine in Alberta. The letter reveals prior communications regarding system failures and compromised patient care dating back to 2008. It also contains a grim prediction “Again, our data and feedback from Emergency Physicians throughout the province indicate that our overcrowding problem continues to worsen and we anticipate the potential catastrophic collapse of timely emergency care delivery in the upcoming months. There must be an intervention immediately.”
Preventable adverse events are driving us down the road to patient safety. How far have we come? From a patient perspective, I believe we are halfway between nowhere and somewhere. It’s time to take a new direction and it’s up to us, as patients, to help lead the way.