Introduction
In the article “Clinical Governance Breakdown,” Cleary and Duke (2019) focus on the cases of willful blindness and whistleblowing in two Australian hospitals. Whistleblowing is a process that involves identifying an incompetent, unethical, or illegal situation and reporting this situation to the authorities (1, p. 1039). This process is rare among nurses due to willful blindness and hostility toward whistleblowers. Willful blindness can be defined as a process “by which the brain filters and edits what it takes in, only admitting” information that makes a person feel good about themselves and filtering information that may unsettle their egos and beliefs (1, p. 1040). The authors examine two cases of whistleblowing and willful blindness that occurred in Bundaberg Base Hospital (BBH) and Macarthur Health Service (MHS) in 2003-2004. In both cases, patient safety was under hazard due to the clinician’s incompetence and willful blindness of the supervisors and managers.
The Primary Causes for the Systemic Risk for Patient Safety
In the first case, the primary cause for the systemic risk for patient safety was surgical incompetence. The BBH could not find adequate and competent surgeons and did not check the overseas-trained medical practitioner Dr. Patel’s background. As a result, many patients suffered from post-operative complications and died from complications. Although the nurses reported Dr. Patel’s negligence and incompetence to higher executives, their complaints were ignored. This case is an illustration of willful blindness and motivated reasoning, as well as systemic inaction. Thus, the BBH Director of Medical Services only acknowledged positive information about Patel’s practice and was willfully blind to the surgeon’s failures and complications (1, p. 1043). The Director’s willful blindness was caused by his desire to avoid complaints that might directly affect funding and the reputation of the hospital.
The second case examines the systemic inaction of the hospital supervisors and their unjust management of the cases reported by nurses. Several nurses of the MHS reported their concerns about the safety precautions that needed to be taken before proceeding with an operative procedure on a 10-year-old child (1, p. 1044). However, their complaints were willfully blinded. Moreover, supervisors claimed that the nurses filed the case not due to patient safety breaches but due to the conflict that occurred between them and other nurses (1, p. 1045). Hence, the primary cause for the systemic risk for patient safety was willful blindness and systemic inaction in the MHS.
Critical Analysis of Why These Risks Occurred and Resulted in Patient Morbidity and Mortality
Having reviewed both cases represented in the article, one can assume that the risks occurred due to the hospital managers’ and supervisors’ willful blindness and unwillingness to argue and have conflicts. Their disinclination to investigate, critically analyze, and address the cases can be explained with the help of the Critical Social Theory. According to this theory, the crisis in the social system and the self-(mis)understanding may be the reasons for willful blindness among the executives of the healthcare facilities (1, p. 1041). In modern society, a reputation of a medical establishment is essential for receiving funding and attracting patients. If the hospital has many complaints and cases of whistleblowing, its reputation will suffer, and the state or investors will decrease or stop funding. Therefore, many executives prefer to close their eyes to such cases and complaints and pretend to see just what they want to see. As a result, the risks of patient safety breaches occur, and patients may suffer from complications and, in some cases, die.
In addition, overconfidence is another cause of the risks that occurred in the two hospitals mentioned above. The first case demonstrates that the surgeon Patel was too self-confident and did not accept the ideas and advice from other colleagues, which led to adverse patient outcomes. Lowenstein (2019) claims that overconfidence is often a result of personal bias (2, p. 127). The surgeon might have believed that esophagectomy was a simple procedure and that the patients without complications would not need to stay in the Intensive Care Unit (ICU). However, this belief was mistaken, and the BBH could not save the patients because of the lack of ICU facilities and staff. If the surgeon had listened to the other health care professionals, the patients would have survived.
The human factor is also a cause of the safety risks at one of the hospitals mentioned above. In the second case, the nurses argued that the patients’ deaths and injuries were the outcomes of negligence and carelessness of the clinical practitioners (1, p. 1044). The fact that their complaints were ignored can be identified with the system (organizational) factors negatively affecting patient safety (3, p. 2). Organizational factors are the conditions under which health practitioners work. At MHS, the conflict between the nurses and the anesthetist occurred because of the hierarchical order at that hospital. The nurses’ opinion might be considered less important than that of a physician, anesthetist, or other health care professional whose level of education is higher than that of nurses. Thus, their complaints were ignored despite the evidence they provided to the MHS managers. As a result, patient safety risk took place, and both human and organizational factors could be associated with this risk.
One can assume that the risks mentioned above resulted in significant patient morbidity and mortality because of the patient harm. This harm could have been prevented, but the ignorance and negligence of the surgeon and anesthetist had led to patients’ deaths. According to Panagioti et al. (2019), patient harm is a process that arises from the actions a health care provider takes or does not take while providing care to their patients (4, p. 1). The facts that the anesthetist refused to address all safety precautions and the surgeon ignored the necessity of post-operative processes demonstrate the patient harm that could have been prevented. However, willful blindness of the authorities resulted in patient morbidity in both cases.
Examples of the Systemic Risk for Patient Safety that Has Occurred in Current Work Environment
The cases of willful blindness and the systemic risk for patient safety are not rare in my work environment. One of the examples of such cases was the surgeon’s overconfidence. The surgeon performed unnecessary operations and inappropriate procedures, which led to patients’ injuries and deaths, but the hospital’s authority refused to notice his failures. Similarly, Iacobucci (2020) describes the case that happened at private hospitals in England. The consultant surgeon wounded patients with intent, but his authorities showed “a lack of curiosity” about his practice (5, p. 1). In that case, the surgeon was jailed for fifteen years, but in my practice, he was only fired. One can suggest that the systemic risk for patient safety has occurred due to willful blindness of the hospital’s government. The main reasons for such blindness were the director’s unwillingness to damage the reputation of the healthcare establishment and a fear of losing potential patients and financial investors.
Another example of the systemic risk for patient safety is the prevalence of medical errors in the public sector. Since public hospitals are usually overcrowded, the risks for medical errors are higher than those in private sectors. In my work environment, I noticed that many medical errors occurred due to the lack of disciplinary actions and an unacceptance of whistleblowing among health care practitioners. According to Khoshakhlagh et al. (2019), the lack of a safety culture in healthcare workers may result in frequent medical mistakes and ignorance of their existence (6, p. 2). If, for example, a nurse makes a muddle of medications and gives a wrong drug to a patient, but no one punishes them for such an action, the risk for similar errors will grow in the future. In my practice, the most frequent mistake or blunder was the moment when a nurse forgot to give a medication or replace a dropper. The head nurse failed to report such cases because she did not want to receive a reprimand.
One can see that supervisors may be willfully blind to medical errors when they want to evade conflict. However, if a healthcare facility does not promote disciplinary actions and does not provide any feedback on errors, the cases of patient safety breaches will continue to happen. To avoid such situations in the future, hospitals have to address each case that occurs due to health care practitioners’ negligence, ignorance, patient harm, overconfidence, or any other reason.
Evidence-Based Solutions to Address the Systemic Risks for Patient Safety
Healthcare facilities should utilize a problem-solving approach to address patient safety and decrease the risks of errors that may lead to patients’ morbidity and mortality. The first step to minimize the systemic risks for patient safety is “the creation of a patient safety culture” (7, p. 4). A recent study in the United States showed that “a stronger patient safety culture was associated with higher patient safety performance and degree” (7, p. 12). If hospitals want to create a patient safety culture, they should develop and encourage leadership, collaboration, communication, evidence-based care, and education among the employees (7, p. 12). Moreover, a just and patient-centered environment should be established. Managers and supervisors should promote patient safety and provide constant feedback about medical errors and areas of improvement. If patient safety culture is strong and all managers and supervisors are taught to support it, the number of systemic risks will be minimized.
A Risk Identification Framework can also be used to predict and prevent patient safety risks and adverse health outcomes. The research by Simsekler et al. (2018) showed that the implementation of the Risk Identification Framework (RID) was positively associated with patient safety culture and risk mitigation (8, p. 20). The risk assessment model consists of four phases: “identify, analyse, evaluate and manage” (9, p. 396). This framework allowed health care practitioners to identify and assess potential risks, plan future work based on this assessment, and improve the sense of risk identification in general. The participants of the study reported that the RID framework was a “helpful addition” that can be used to discover the reasons for hazards and help managers and clinicians manage risk in the future (8, p. 19). Thus, the RID framework, or other similar tools and applications, can be used in healthcare to mitigate patient safety risks and better evaluate the potentially hazardous situations in clinical practice.
Conclusions and Implications
Systemic risks for patient safety usually occur due to the health care providers’ incompetence and willful blindness of the supervisors and leaders. When administrators obtain reports of patient safety breaches, they often pretend to ignore such reports because of a fear of conflicts and personal biased views. In some cases, a patient will get off with fright or injury. However, the fatal outcomes of such willful blindness and constant ignorance of safety breaches are patients’ morbidity and mortality.
If leaders want to prevent adverse outcomes in their practice, they should cultivate moral courage and confidence and create a patient-centered environment in their health care establishment. Personal awareness of adversarial feelings and emotions should also be developed. Leaders need to understand that they may be unable to evaluate the situation critically at the moment when they receive a complaint. Therefore, they should reconsider it later, after conducting an investigation and interviewing other colleagues about the case. Moreover, hospitals may use Risk Identification Frameworks to analyze the existing patient safety risk and predict and prevent future risks. Even though this framework has some limitations, such as an inability to predict all potential risks, it may be used as an additional tool in patient safety management. In conclusion, patients’ safety and wellbeing should be of the highest priority to all medical workers. Leaders should not ignore whistleblowing because such reports may save patients’ lives. The role of the leaders is to listen to each side of a case and take action only when the full story is heard and investigated.
References
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