Unoffical Guide to Medicine Essay Competition – Secondary School Runner-up: Aleksandra Skroban

Well done to Aleksandra on being a runner-up in the secondary school category of our ‘Unofficial Guide to Medicine Essay Competition’ for her essay on “Doctor accountability and ‘no-blame’ culture as instruments to reduce ‘never events’ “

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In recent years there has been increased interest in patient safety in the healthcare environment with the emergence of statistics that are suggestive of what can be considered high instances of ‘never events’ despite seemingly more extensive pre-operative protocols and procedures. ‘Never events’ are identified as wholly preventable errors in medical care that can yield detrimental effects on patients (serious harm or death) and are indicative of issues with regards to the safety and credibility of healthcare providing facilities (Centres for Medicare & Medicaid Services, 2006) and include examples such as wrong site surgery, medication errors and the retention of foreign objects post-procedure. Whilst in some situations organisational influences of the healthcare facility may be responsible for a ‘never event’, in most cases causes are attributed to individuals. According to NHS England (2016) 306 incidences occurred between 1 April 2014 and 31 March 2015 that met the definition of a ‘never event’ whilst the figure between 1 April 2013 and 31 March 2014 was 340. If the aim is to achieve an absolute minimum of ‘never events’, then perhaps a shift in attitudes, deterrents, repercussions and protocols needs to be introduced. Therefore when considering what approach to implement, whether it be a greater focus on the individual accountability of doctors or adopting an emphasis on learning from mistakes -the cause of the event and implications on the doctor, the patient and the healthcare system itself must be addressed.
One cause of ‘never events’ are unsafe actions. Consider a ‘never event’ in which recklessness in conduct is the cause which results in the patient being put in unnecessary danger, excluding that which is associated with the procedure itself. Here it can be argued that accountability must be implemented if the ethical responsibility of a doctor is to treat a patient (to the extent to which their knowledge and current technological, procedural availability allow) with the full understanding that they yield responsibility for their actions. A case such as this clearly violates a patient’s safety which is ‘the freedom from accidental injury’ (Kohn et al., 2000). By not applying such stringent measures, it can be said that similar events due to negligence (whether intentional or not) will continue to occur as there is an awareness of the fact that more severe repercussions will not be set into place. It is also important to discuss the extent of the harm that is inflicted upon the patient when discussing accountability: theoretically all ‘never events’ should be treated with the same gravity as in every case the event is wholly preventable, breaches the patient’s safety and has the potential to cause fatal effects. Hence regardless of the severity, Root Cause Analysis (RCA) should be undertaken by the healthcare facility to identify the factors responsible for the ‘never event’ whether they are associated with individuals or systems in order to allow for the implementation of appropriate preventative measures. This facilitates the opportunity to learn from previous mistakes whilst ensuring that those accountable claim the consequences for their actions hence not compromising a patient’s rights to safety.
Holding hospitals and healthcare providing facilities financially accountable for ‘never events’ may act as another method of deterrence and an incentive to implement procedures to prevent such occurrences. For instance, as of 2008 Centres for Medicare and Medicaid Services (CMS) do not pay hospitals ‘any increased rate or any cost attributed to care made necessary by hospital acquired conditions’ and do not permit these costs to be imposed upon a patient (Centre for Medicare Advocacy, 2008). This increases the potential financial burden upon a healthcare centres and facilities in the case of such events and is indicative of a zero-tolerance policy towards negligence by treating ‘never events’ as occurrences that should, as the name suggests, never happen. The aim of this is to allocate greater attention to improving patient safety through ensuring correct diagnosis is made upon admission and that any other procedures are mediated by a series of protocols that minimise the risk of human error. A possible argument against this is that it may lead to some discrimination in the admittance of a patients who possess a high risk of developing complications during and after treatment.
While some causes of ‘never events’ can be attributed to individuals, others can be multifactorial perhaps resulting from organisational influences. According to Thiel et al. (2015) ‘the majority of medical errors are believed to be the product of inadequately designed systems which permit predictable human errors’ but individuals still yield responsibility in contributing to and preventing potential ‘never events’. This clearly illustrates the need of having an understanding of the ‘culture of blame’ and ‘culture of no-blame’ that can fundamentally underpin the ways in which a ‘never event’ in a particular healthcare environment is approached.
The culture of blame in the context of a ‘never event’ would involve focusing on identifying the individuals responsible. A hard-line approach towards accountability could act as a deterrent (as discussed) but could equally potentially encourage hesitancy in reporting ‘never events’ due to a fear of repercussions, leading to a further compromise of a patient’s safety and wellbeing.
The nature of a no-blame culture directs a different approach. Its aim is to improve the quality of care by learning from mistakes and as a result imposing safeguards to ensure that they do not happen again (Elmqvist et al., 2016) –it focuses on identifying and understanding the root cause of an occurrence rather than solely identifying those who are responsible and introducing a resolution to the problem based upon this. An example is that which regards surgical sponges. The problem identified was that in 1 in every 5,500 operations, foreign objects were retained and that in 68% of these incidences sponges were involved (Treadwell, 2013). This is suggestive of an issue involved in the system of counting of surgical instruments that can be perhaps influenced by human factors such as failing to follow the counting procedure correctly and negligence. A solution to the problem was to use a bar coding system to count the sponges pre- and post-operatively to ensure none were retained in patients. This particular example illustrates that while in a particular ‘never event’ one individual may be identified as being responsible for miscounting the sponges, this could in fact be a flaw in the procedure itself rather than a fault of the individual –which in a culture of blame would be the only focus.
Overall whilst a doctor may be responsible in varying degrees for a ‘never event’, there usually is a fault in the system that allows this to occur -there is co-responsibility. Therefore an individualistic focus on either systemic influences or human factors is insufficient when looking to reduce incident frequency –an approach that encompasses both is necessary. The first step would be to make reporting ‘never events’ a routine procedure to allow for effective RCAs to be conducted that would be illustrative of potential organisational influences that can have an effect on ‘never events’. The second step should involve the implementation of preventative measures to resolve any issues that arise during RCA. Thirdly, individuals identified in the RCA as responsible should be held accountable for their actions which is imperative and in accordance with ‘never events’ being considered unacceptable. While ‘never events’ may never be diminished to a zero level due to the sometimes unpredictable nature of human factors and error –a functional, preventative approach of accountability and a culture of safety should yield significant effects and as a result improve patient safety as a whole.

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References

• Centre for Medicare Advocacy. (2008) CMS to hospitals: if it should never happen, we will never pay. Centre for Medicare Advocacy, Inc. Available from: http://www.medicareadvocacy.org/old-site/InfoByTopic/Reform/Reform_08_09.25.NeverEvents.htm [Accessed 30th January 2017].
• Centres for Medicare & Medicaid Services. (2006) Eliminating serious, preventable, and costly medical errors – Never Events. Available from: https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2006-Fact-sheets-items/2006-05-18.html [Accessed 21st January 2017].
• Emlmquivst, K. O., Rigaudy, M. TJ. & Vink, J. P. (2016) Creating a no-blame culture through medical education: a UK perspective. Journal of Multidisciplinary Healthcare. (9)345–346. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4982483/ [Accessed 21st January 2017].
• Kohn, L. T. (ed.), Corrigan, J. M. (ed.) & Donaldson, M. S (ed.). (2000) To Err is Human: Building a Safer Health System. Washington DC, National Academies Press US. Available from: https://www.ncbi.nlm.nih.gov/books/NBK225171/ [Accessed 30th January 2017].
• NHS England. (2014) Never Events reported as occurring between 1 April 2013 and 31 March 2014. NHS England. Available from: https://www.england.nhs.uk/patientsafety/wp-content/uploads/sites/32/2015/09/2013-14-NE-data-FINAL.pdf [Accessed 21st January 2017].
• NHS England. (2016) Never Events reported as occurring between 1 April 2014 and 31 March 2015 –final update. NHS England. Available from: https://www.england.nhs.uk/patientsafety/wp-content/uploads/sites/32/2016/01/provsnl-ne-data-2014-15.pdf [Accessed 21st January 2017].
• Thiels, C., Lal, T. M., Nienow, J. M., Pasupathy, K. S., Blocker, R. C., Aho, J.M., Morgenthaler, T. I., Cima, R. R., Hallbeck, S. & Bingener, J. (2015) Surgical Never Events and Contributing Human Factors. Surgery. 158(2), 515–521. Available from: http://www.surgjournal.com/article/S0039-6060(15)00315-3/abstract [Accessed 27th January 2017].
• Treadwell, J. R. (2013) Making Health Care Safer II: An Updated Critical Analysis of the Evidence for Patient Safety Practices. Agency for Healthcare Research and Quality (US). Report number:211. Available from: https://www.ncbi.nlm.nih.gov/books/NBK133403/ [Accessed 30th January].

Bibliography

• NHS England. (2015) Never Events List 2015/16. NHS England. Available from: https://www.england.nhs.uk/wp-content/uploads/2015/03/never-evnts-list-15-16.pdf [Accessed 21st January 2017].
• Theimer, S. (2015) How does human behaviour lead to surgical errors? Mayo Clinic Researches Count the Ways. Available from: http://newsnetwork.mayoclinic.org/discussion/how-does-human-behavior-lead-to-surgical-errors-mayo-clinic-researchers-count-the-ways/ [Accessed 27th January 2017].
• White, J. (2015) Avoid ‘never events’ in surgery: 4 areas to watch. Available from: http://www.healthcarebusinesstech.com/avoid-never-events-surgery/ [Accessed 27th January 2017].