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Patient safety has become a major concern in the healthcare sector because of the prevalence of medical errors (Pillow 2007, 152). Patient safety has even stood out as its ideal discipline and it encompasses certain areas of healthcare service providers such as reporting, analysis, and prevention of medical errors (because of the upsurge of medical errors across the globe).
Initially, medical errors were not considered a big issue in medical circles until there was an increasing trend of medical errors across the globe which resulted in adverse medical events and a high number of patient deaths. This trend prompted the World Health Organization (WHO) to assess the impact of medical errors across the globe and established that at least one in every ten patient across the globe are normally affected by medical errors (World Health Organization 2008).
Indeed, in recent years, the world has been shocked by medical documentaries exposing the prevalence of medical error and its ability to cause adverse medical events. For instance, in April 1982, America was treated to a very shocking documentary titled the deep sleep that showed the number and kinds of medical errors that occurred as a result of anesthesia accidents that were estimated to affect about 6,000 American patients who later suffered brain damage or other adverse medical events (Ellison 2011).
The same concern has also been registered in Britain and Australia where patient safety was brought into sharp focus by the Royal Society of Medicine, Harvard medical school (in Britain) and the Australia patient safety foundation (in Australia) (Ellison 2011). In Australia, it is estimated that about 18,000 medical deaths are a result of medical errors and in Canada, it is estimated that about 9,000 to 24,000 patients die of preventable medical errors annually (Ellison 2011). In Canada, this statistic amounted to about 7% of all healthcare admissions. Global statistics show the same trend because it is estimated that about 44,000 of 98,000 deaths that happen in the healthcare sector are caused by medical errors and about 7,000 of such deaths occur as a result of preventable medical errors (Charatan 2000).
These statistics abound, many observers have shifted their attention from the shocking statistics to the real causes of medical errors. Comprehensively, it is established that medical errors are either caused by human factors or medical complexities. Human factors include variations in training healthcare workers; fatigue; depression; burn out; dealing with diverse patients; coping with unfamiliar settings and time pressures and finally the failure to acknowledge the seriousness and prevalence of medical errors (among others).
Medical complexities may include the combination or exclusion of complicated technologies, powerful drugs, and intensive care or prolonged hospital stay. Though these factors may contribute to a significant extent in the upsurge of medical errors, there is a neglect of one main cause of medical errors – system failures. Focus on system failures changes the paradigm of how medical errors are analyzed because it shifts the focus from blaming healthcare personnel to the procedures and rules followed when treating patients. This study exemplifies the point of view that, designing safety systems in the healthcare sector plays a crucial role in the reduction of medical errors.
To explain this point, this study will sufficiently analyze the determinants of medical error occurrence by factoring all argument information which pertains to the occurrence of medical error as a unique ethical problem. A paradigm shift from human factors to medical systems will thereafter be done to establish the role medical systems play in the occurrence of medical errors (viz-a-viz human factors). Finally, the study will conclude by establishing that, a change in a paradigm shift, from a human error to system failures will effectively work towards reducing medical errors.
Experts have often said that there is no discipline where laws and ethics probably conflict more than the healthcare sector (Kutz 2000). Though law and ethics are normally designed to be in harmony with one another, the healthcare sector seems to be an exception because harmony between the two is hardly evidenced. This is especially true concerning the disclosure of medical errors. The debate on the disclosure of medical error is essential because often, the people who witness such errors are put in a compromising position on whether to disclose such errors or not.
The conventional manner of going about such a situation is to be silent about it, but ethically, this is not correct. For instance, if a medical student witnesses a medical error during an operation and though it does not result to death, it results into the excessive stay of the patient in the hospital, it is a huge dilemma for the student whether to report the errors or not (since it is not his fault, but the physician’s fault). At the same time, the patient needs to know what happened during the operation to warrant his long stay in the hospital.
Besides the dilemma medical practitioners face in reporting medical errors, patient autonomy is an important element in the analysis of medical errors because it is often a dilemma for many health practitioners to follow patient preferences or their professional expertise regarding a given issue. For instance, in a country where abortion is illegal and unethical and a patient requires a doctor to carry out the procedure anyway, it becomes very difficult to determine whether it is right to do the procedure or not. The dilemma is even stronger because whichever decision the doctor chooses; it has a negative or controversial impact. For instance, if the doctor refuses to undertake the procedure, would it mean that he or she is imposing their values on the patient?
In close relation to this thought, if the doctor declines to undertake the procedure, would it not mean that the patient may decide to undertake the same procedure elsewhere, in an unhygienic surroundings, thereby putting the patient in more risk? Such kind of situations are normally faced by many health experts and it is even more unfortunate for doctors because such a dilemma cuts right in the middle of the most basic and controversial ethical dilemmas existent in the medical sector. In the entire scenario above, there are two distinct but related issues. The first is the patient’s autonomy in making decisions regarding her health and the second issue is the doctor’s professional values which contribute to the decision on whether the procedure should be done or not.
A second scenario can be best explained in a situation where a mother brings her daughter for female circumcision, in a hospital setup, as opposed to the local village setting where it is unhygienic for such operations to be done. Again, in this situation, the doctor will be faced with the same dilemma of performing the procedure to limit the risk the child faces when the procedure is done in unhygienic conditions or carry out the procedure at the expense of being termed unethical. The other alternative approaches to be taken would be to report the incident to the police (but no crime would have been committed) or send the patient away, but the chances of other parents coming to the hospital with the same kind of problem may be very minimal.
Also, another significant problem attributed to the upsurge of medical errors is workforce issues. Workforce issues range from several problems such as poor staffing, poor pay, poor work environment, and the likes. Though these issues may seem rather inconsequential to medical errors, their impact is often felt far and wide. Very few countries across the globe meet their healthcare personnel needs (including the most developed countries such as the US).
Normally, in most countries, the demand for healthcare practitioners exceeds the supply of the same. This situation means that patient-nurse or the doctor-patient ratio is often not met and therefore more healthcare practitioners are likely to be overworked. This fact is supported by Runciman (2007, 71) who identifies that overworking can adversely affect worker performance and consequently lead to the increase of medical errors.
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In other medical literature excerpts, it is affirmed that a shortage in staff is likely to lead to high nurse turnover; increased nurse workload; increased risk of spreading infections to patients (a form of medical error); increased risk of occupational injury; increased death and increased perception of poor working conditions. Developing countries bear the greatest burden of worker issues related to staffing because several such countries normally export their workers to wealthier countries and therefore leave their healthcare systems vulnerable to medical errors due to staffing issues. This kind of situation often leads to an upsurge of medical errors due to fatigue or employee burnout.
Job satisfaction has also been identified as one of the primary motivators of healthcare providers, not only in the corporate environment but also in the healthcare sector. As a result, staffing issues become a pressing issue if the statistics reflecting the increased number of medical errors are to reduce. If staffing issues are not addressed, there is a very small chance that healthcare personnel will be satisfied with their work and in the same manner; the chances of medical errors occurring will be high as a result (Runciman 2007, 71).
This relationship withstanding, it is critical to note that the occurrence of medical errors is not primarily caused by the individual (healthcare practitioner) but rather, the conditions that surround the individual. The conditions surrounding the individual refer to the conditions prevailing in a country’s healthcare sector and most often; such conditions are dictated by policies and procedures. This, therefore, means that if policies and procedures are reformulated, the chances of reducing medical errors will be higher
Currently, the debate on medical error is centered on how they can be reduced without necessarily putting a lot of blame on the healthcare personnel involved. In the disclosure of medical errors, many health institutions have often been affected by the “blame game” syndrome whereby if a medical error occurs, the one who bears the most responsibility is pointed out (Kutz 2000 142). This approach is widely observed to be repugnant to the goal of eliminating medical errors in health institutions, as well as reporting incidents of medical errors because it is based on the individual as opposed to the processes or procedures in the healthcare sector.
Runciman notes that a healthcare institution can get the best out of its workforce by simply eliminating instances of pressure among its workers (Runciman 2007, 221). Such sort of pressure is exhibited from the need to take individual responsibility for a given error. This kind of culture is normally deemed the “fair and just” culture because it eliminates instances of blame and punishment because forbidding medical errors does not mean that medical errors will reduce (Runciman 2007, 209). In any case, the errors will occur, and most of them will be concealed.
However, it should not be assumed that eliminating individual blame means that an institution’s disciplinary system should be eliminated as well; it means that when an error occurs, medical administrators should investigate the systems that led the healthcare personnel to commit the medical error in the first place (as opposed to the individual). Blame is not assigned to the individual in this case. Eliminating the culture of individual blame is normally representative of a future strategy to eliminate future medical errors because if blame is assigned to an individual, and the individual is punished as a result, such a strategy would only seek to solve the short-term occurrence of medical errors but medical errors would still occur in the long-term.
Several sociology researchers and healthcare practitioners such as Vincent (2010, 119) have thrown their weight behind eliminating the culture of “individual blame” and instead proposed a thorough insight into system design as a major cause of medical error because according to their findings, individual blame instills fear in people and therefore acts counter-progressive to the goal of eliminating medical errors. In most cases, the “individual blame” culture is also known to lead to the adoption of defensive medicine which normally occurs when healthcare practitioners undertake several unnecessary medical procedures, or on the contrary, avoid many high-risk procedures so that they reduce the chances of being slapped with a lawsuit in case of the occurrence of a medical error.
This fact is affirmed by Runciman (2007, 221) who notes that the culture of individual blame is likely to lead to an increase in defensive medicine as opposed to the goal of promoting safety. Defensive medicine may occur as either positive defense medicine or negative defense medicine. This sort of trend has been associated with the increase of medical malpractice litigation, and from a general point of view, it increases the cost of healthcare, or in the same manner, increases the exposure of patients to medical errors.
The culture of individual blame can be said to be the cause of the increase in defensive medicine because it instills fear among medical practitioners. This approach means that a different paradigm needs to be adopted to eliminate medical errors and the concept of blaming individuals for medical errors does not work towards eliminating instances of medical error. The importance of designing an effective safety system can therefore not be overemphasized at this point because a comprehensive healthcare safety system comprehensively attacks the problem of medical errors (Vincent 2010, 211).
In a study done by Hopkins Institute to analyze the disclosure of medical errors among doctors, it was established that about 80% of doctors in America who have committed medical errors do not report them because they run the risk of being sued (Johns Hopkins Medicine 2009). A medical expert at Hopkins institute (cited in Johns Hopkins Medicine 2009) affirms that: “Our preference during the last decade for not assigning blame to individuals went a long way to encourage the disclosure of medical errors and getting buy-in for the idea that systemic safety problems existed and could be fixed” (12).
From the changes implemented at Hopkins institute, it was confirmed that incidents of wrong-site surgical error and bloodstream infections were greatly reduced as a result of the elimination of the culture of individual blaming. However, these changes do not mean that incidents of medical error can be eliminated by eliminating the culture of individual blaming. As a result of the change in contextual analysis, a different approach to enforcing accounting systems and enforcement policies should be carried out so that healthcare practitioners are prevented from committing more medical errors.
In reducing such medical errors, the concept of professional values is also important to medical practitioners in achieving such an objective because it is affirmed that, doctors are normally influenced by stipulated guidelines in the medical profession. Not only do these guidelines work towards the elimination of medical errors, but they also work to eliminate any instances of discrimination against patients and affirm the primacy of patient welfare because they redefine professional behavior in terms of upholding doctor integrity and honesty.
BMJ Publishing Group Ltd acknowledges that professional values “work towards avoiding conflicts of interests, improving patient care and the overall delivery of healthcare services” (BMJ Publishing Group Ltd 2011, 18). However, professional values vary from one geographical location to another because doctors are often influenced by their national perception of patient care and this consequently affects their professional values. Doctors’ professional values are very important in the elimination of medical errors because within the doctor professional code of conduct, a doctor is supposed to oversee the activities of another doctor and if any instance of unprofessionalism, a doctor is supposed to report his or her colleague. This provision is often not adhered to.
There is adequate research evidenced by several medical studies to suggest that doctors’ professional values are normally influenced by external factors. This fact supports several growing literature supporting a change in the external medical environment to reduce instances of medical errors. BMJ Publishing Group Ltd affirms that “We believe that as well as promoting high standards of behavior from within their professional societies, it is important for doctors to advocate for healthcare system reforms that uphold high standards of behavior” (BMJ Publishing Group Ltd 2011, 19). However, the call to reform the healthcare sector is deemed to be an internal affair because many doctors are pressured to improve existing healthcare systems to reduce the chances of medical errors.
The Paradigm Shift to Safety Systems
Gaining a comprehensive analysis of the real causes of medical errors will make it easier to understand how medical errors occur and consequently change the judgmental lens through which many health practitioners have been perceived. This point of view is also shared by Vincent (2010, 141) who establishes that, in eliminating instances of medical error, it is important to understand how things go wrong in the first place. In a study done to investigate the progress of recipients of liver and kidney transplants, it was established that 93 of the 149 cases studied suffered instances of medical error resulting from patient error as the most common type of error (Science Daily 2007).
This type of error constituted approximately 56% of the errors studied and only a mere 13% of the errors were as a result of the wrong prescription. It was further established that 13% of the errors registered were as a result of wrong delivery; 10% of the errors were as a result of the availability of the drugs (because some patients did not have full-time access to the drugs) (Science Daily 2007). A further 8% of the errors were as a result of a wrong report of the condition by the patient, such that, the healthcare provider was misled into giving a wrong dosage or prescription of the drugs.
From this analysis, we can see that a great percentage of the medical errors that occurred either emanated from system flaws or the patient’s side. More so, the contribution of patients to the occurrence of medical errors is further reiterated by Vincent (2010, 141) who notes that patients need to be involved in designing efforts to reduce medical errors for their safety. Nonetheless, only a paltry 13% of the errors could be traced to the healthcare service providers. This means that attributing medical errors to individual healthcare practitioners is a wrong approach because they do not hold a greater percentage of responsibility leading to medical errors.
A different approach, therefore, ought to be considered and instead of focusing much attention on medical personnel, the focus should be shifted to everybody who makes the healthcare process a success. This means that patients, administrators, and healthcare personnel should all be considered in eliminating the occurrence of medical errors. For instance, in the above study, it was confirmed that medical errors occur as a result of three causes: medical personnel, patients and system flaws. System flaws can easily be rectified through liaison with healthcare administrators to correct or enforce the system to be more efficient.
This approach would include the accountability strategy mentioned in earlier sections of this study. To eliminate the possibility of errors occurring as a result of patient or health personnel errors, both parties need to be included in the efforts to improve the efficiency of healthcare services because patients play a critical role at the input stage of healthcare service provision while healthcare personnel plays a critical role at the output stage of the same process. From this analysis, the focus on systematic flaws is therefore very important in the reduction of medical errors.
According to Runciman (2007, 247), systemic flaws are large to be blamed for the high number of medical errors because over the years, many health administrators have failed at getting the best out of the healthcare system. The Hastings centre also shares the same sentiments when they state that “Many errors can be traced to flaws in complex systems of healthcare delivery, not flaws in individual performance” (The Hastings centre 2011, 5). These revelations come amid increased blame on healthcare workers for their apparent neglect of safe healthcare practices.
Lynch notes that there needs to be a paradigm shift in the analysis of medical errors from healthcare workers to patients because patients also contribute significantly to the occurrence of medical errors (Lynch 2008, 57). This fact can be traced to the ethical principle of patient autonomy because, in as much as patients are left to have their own say about their health, the allowance of this ethical principle significantly contributes to the occurrence of medical errors. This is true because when medical experts leave patients to have their say, regarding medical decisions, patients’ views may divert from the medical practitioners’ (regarding the best medical courses to take for patient’s treatments).
This significantly adds to the growing number of cases of medical errors. Since patient autonomy is part of the ethical principles supposed to be upheld by health experts, it is important to instill this ethical principle in healthcare systems because a middle ground can be established to let patients have their autonomy and still allow medical experts to also contribute to the discussion on how to improve the health of the patients. Having this middle ground can therefore only be achieved through redefining the healthcare system. Such an assertion only seeks to reinforce previous calls to change the paradigm shift of the analysis of medical errors to systems, so that the prevalence of medical errors can be effectively reduced.
This is one method through which people can bestow their trust again on the healthcare system and it is also a platform through which subsequent reforms can be done. One such reform is encouraging a culture of accountability when handling medical errors. Kutz (2000, 20) identifies the virtue of social accountability as a basic platform through which doctors can improve their ethical conduct. The element of accountability deals with the restructuring of responsibility for medical mistakes and shifts the blame from individuals to rules, procedures, and policies (Kutz 2000).
This, therefore, means that justice will be achieved for the injured people and statistics obtained from the process can also be utilized to further improve the system (in the prevention of future errors). The entire essence of changing or reinforcing accountability standards is aimed at replacing existing health rules, procedures and policies to be more ethically conscious so that there is a culture of honesty regarding patient safety and a culture that upholds the compensation of patients when medical errors occur.
This fact is in line with the ethical principle of beneficence because it goes a long way towards ensuring the ethical good of every stakeholder in the healthcare system is improved (but more so, for the patients). The principle of beneficence seeks to ensure that, the interests of the patients and health centers are firmly taken care of, but there is no way such public good can be achieved without factoring it into the healthcare systems of healthcare institutions.
For instance, redefining the accounting systems of medical institutions go along way towards ensuring the public good of the hospital administrators is achieved and in the same manner, if efficiency is upheld in the healthcare sector, patients can be able to enjoy better services, and this will ultimately reduce the occurrences of medical errors. The principle of beneficence can, therefore, be upheld only through a redefinition of the healthcare system.
Another frontier where the paradigm shift of analyzing medical errors (from human factors to systemic factors) can be encouraged is the redefinition of medical boundaries. This is true because the contravention of medical boundaries has been advanced as a major cause of the medical error but contrary to public perception, medical boundary contravention is majorly a systemic flaw rather than a human factor issue. Analyzing medical boundaries is a new frontier in the fight against medical errors.
The edge of professional conduct, in this case, refers to the boundaries doctors are supposed to operate when dealing with their patients. A contravention of this framework has a significant impact on the ability of a doctor to make medical errors because his or her standards may be compromised, thereby putting the patient at risk. From this analysis, human factors play a small role in the occurrence of medical errors. The same can however not be said for the systemic framework.
Though the breach of medical boundaries is largely a matter of personal judgment, systemic flaws are largely prominent in this case because policies and regulations have a crucial role to play in the comprehension of medical boundaries. Because medical boundaries can sometimes be difficult to establish if the context is not analyzed, it is important to note that medical boundaries can only be best articulated through rules and policies governing the same. The ethical principle of not harm prominently surfaces at this point because medical experts must not harm their patients. This duty or responsibility is best upheld through medical boundaries between patients and medical practitioners.
The ethical principle of not harm is close to the medical principle of non-maleficence because they both articulate that, it is in the best interest of medical practitioners to refrain from doing any harm to their patients, first, than to do good. This principle has been affirmed as the primary principle medical experts should look into because new medical experts are known to use new courses of treatment to “do good”, but they fail to evaluate the new treatment bases with regards to their possibility of harming their patients. The focus on medical boundaries is one way through which medical experts can uphold the principle of no harm but to achieve such a goal, systemic flaws ought to be changed first. The focus on systemic flaws can therefore not be overemphasized at this point.
Designing an efficient safety healthcare system will change the paradigm in which medical error occurrence is perceived. It is also ethically correct to adopt this system because it is the fairway through which medical errors should be tackled because research studies identify that, system failures play a big role in the occurrence of medical errors than human factors.
Human error is subject to medical systems and therefore it is important to focus on the root cause of the medical error (medical systems) and not a symptom of the problem (human error). According to research findings established in this study, system failures are known to contribute to the occurrence of medical errors more than human factors. It is established that some of the errors caused by medical practitioners are further caused by misinformation from the patients. This analogy, therefore, exposes the fact that medical practitioners have a very small role to play in the occurrence of medical errors.
Since the occurrence of medical errors is largely an ethical principle, this study establishes that the ethical principle of beneficence, do no harm and autonomy can only be achieved through the elimination of system flaws as opposed to a change in the conduct of healthcare professionals. This is true because policies and principles can only be followed through an affirmation of an institution’s systems as opposed to the reformation of a medical expert’s character.
Conventionally, the focus on the occurrence of medical errors has been centered on human factors but this analogy is misguided because the focus should have all along been centered on system failures. In other words, this study establishes that system flaws are the biggest cause of medical errors and therefore, it is unfair to place all the blame on healthcare personnel. These factors abound, this study proposes a shift in the contextual analysis of medical errors from the individual to the systems involved.
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