THE BURDEN OF UNSAFE MEDICAL CARE

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HEROIC MEDICINE

The axiom ‘first do no harm’ is often mistakenly attributed to Hippocrates. The slight alteration in wording of his injunction originates from a treatise, Physician and Patient, written in 1849 by Worthington Booker, who in turn ascribed the phrase to A.F. Chomel.6 The renewed focus on non-maleficence at this point in western medical history was a reaction to the ascendancy of a more activist, interventionist therapeutic paradigm, referred to as ‘heroic medicine’.7 Sharpe and Faden describe the late eighteenth and early nineteenth century as a period of unprecedented iatrogenic violence. Proponents of ‘heroic medicine’ such as John Brown, Benjamin Rush and others caused considerable harm through their vigorous ‘life preserving’ remedies.8 Essentially, that is what ‘heroic medicine’ epitomised; the preservation of life above all else.9
The prevailing treatments of the early nineteenth century often required heroic bravery from patients! Rush, the ‘founding father’ of American medicine, was a sanguine proponent of blood-letting, calomel purges and mercury filled bilious pills.10 Patients would often have almost half of their total volume of blood withdrawn during one of Rush’s phlebotomies.11 With the benefit of hindsight we can today see that these depletive therapies definitely did more harm than good, but not for one moment should we doubt that patient benefit was the foremost concern at the time.12 Rush’s commitment to his patients’ well-being is evident in his decision to remain in Philadelphia during the yellow fever epidemic.13
How does one reconcile this noble commitment with the consequences of one’s actions? Rush provides a glimpse into his justification therefore by stating that: ‘…it is impossible to calculate the mischief which Hippocrates has done by first marking nature with his name, and afterwards, letting her loose upon sick people. Millions have perished by her hands in all ages and countries.’14 Fighting disease was thus the first duty of a physician, losing a patient in doing so was regarded as a more acceptable outcome than passively allowing the sick to succumb. A doctor who acquiesces to such a death in the absence of adequate therapeutic vigour was deemed to be a murderer and a quack according to Rush.15

A CATALYST FOR CHANGE

Perspectives regarding error prevention have certainly changed in the aftermath of the IOMs findings.33 Hardly acknowledged preceding the report, confronting preventable medical injuries has now become a primary concern. The widely disseminated notion that bad systems, instead of bad people, are responsible for the majority of errors and injuries has become somewhat of a mantra in healthcare. This concept, which emphasises systemic rather than individual failure, has been a critical scientific foundation for safety improvement in high reliability industries, such as aviation and nuclear power operations. The report highlighted the role that technologies can play in achieving safer care. Consequently, the potential benefits that computer-assisted physician order-entry systems and electronic medical records may yield have received considerable attention.
The report managed to galvanise extensive stakeholder support for safety initiatives in the United States.34 The federal government in 2001, earmarked an annual amount of $50 million for patient safety research.35 The financial assistance drew hundreds of new researchers into the field, creating an academic foundation and establishing error prevention and patient safety research as a serious scholarly discipline.36 The cause has also been helped along by key players such as the Agency for Healthcare Research and Quality (AHRQ). Established by an act of Congress in 1999, the AHRQ conducts scientific research and produces evidence to make healthcare safer, enhance quality and increase effectiveness as well as accessibility through the promotion of improvements in clinical and health system practices.37 The AHRQ and its Centre for Quality Improvement and Safety have played a leading role in safety efforts by prioritising education and training, developing safety measures and standards, evaluating evidence-based best practices and promoting better reporting of adverse events.38 Patient safety initiatives also found support in the Veteran’s Health Administration (VHA), which implemented system-wide safe practices and training programs.39 Other important role-players have emerged and taken steps to improve safety, a varied group that includes the: Joint Commission on Accreditation of Healthcare Organizations (JCAHO); National Quality Forum (NQF); Centres for Medicare and Medicaid Services; Centres for Disease Control and Prevention; American College of Physicians and other medical societies; National Patient Safety Foundation; Accreditation Council on Graduate Medical Education; American Board of Medical Specialties; Institute for Healthcare Improvement; purchasers and payers.

RELUCTANCE TO SIMPLIFY9

Mindful organisation recognises the importance of variety and realises those actions and descriptions that can obscure or diminish complexity. The authors note that: ‘Simplification obscures unwanted, unanticipated, unexplainable details and in doing so, increases the likelihood of unreliable performance.’ This includes anomalies and finer-details that may contain warning signs which may be concealed when one relies on generalisations, types and categories. The authors cite the misidentification of the West Nile virus as an example, of where the smoothing over of fine-grained distinctions managed to veil unexpected trouble. The simplification of an unusual assortment of symptoms, resulted in a tentative diagnosis of St. Louis Encephalitis (SLE), which proved to be incorrect. The initial diagnosis disregarded evidence contrary thereto. Muscle weakness, one of the most notable symptoms, had never been associated with SLE. Birds and horses were also affected, which would not be the case with SLE. By simplifying early on, the investigators missed relevant information which would have made the overall picture much clearer.
Mindfulness, emphasises context and detail, slowing down our tendency to view things as similar, allowing us to detect differences more readily. By identifying more differences, we can anticipate more varied consequences, which can shed light on a greater number of warning signs, enabling us to take additional precautions. The Columbia shuttle disaster serves as another cautionary example of the dangers of simplification. NASA were criticised by the Columbia Accident Investigation Board for making themselves guilty thereof. A section titled ‘Avoiding Oversimplification’ was included in their final report. The authors suggest that to organise for reluctant simplification, would entail organising for more process variety, more openness to argumentation, and more capability and willingness to act in order to understand.

CHAPTER 1. A BRIEF HISTORY OF HARM
1. INTRODUCTION
2. HISTORY OF HARM
3. CODMAN AND THE ‘END-RESULT IDEA’
4. IATROGENIC ILLNESS
5. HAZARDS OF HOSPITALISATION
6. MEDICAL NEMESIS
7. CONCLUSION
CHAPTER 2. TO ERR IS HUMAN
1. INTRODUCTION
2. TO ERR IS HUMAN
3. A CATALYST FOR CHANGE
4. INTERNATIONAL AGENDA
5. AFRICA AFFLICTED
6. CONCLUSION
CHAPTER 3. THE BURDEN OF UNSAFE MEDICAL CARE
1. INTRODUCTION
2. THE GLOBAL SCALE OF HARM
3. SIGNIFICANT SOURCES OF HARM
4. CONCLUSION
CHAPTER 4. THE KEY CONCEPTS OF MEDICAL ERROR AND PATIENT SAFETY
1. INTRODUCTION
2. CONFRONTING THE PROBLEM OF MEDICAL HARM – THE KEY CONCEPTS OF MEDICAL ERROR AND PATIENT SAFETY
3. EXPLAINING HUMAN ERROR
4. CONCLUSION
CHAPTER 5. HIGH-RELIABILITY ORGANISATIONS AND SAFETY CULTURE
1. INTRODUCTION
2. MINDFUL ORGANISING – FIVE CHARACTERISTICS OF HIGH RELIABILITY ORGANISATIONS
3. ORGANISATIONAL CULTURE
4. CONCLUSION
CHAPTER 6. JUST CULTURE – BALANCING ‘NO BLAME’ AND ACCOUNTABILITY
1. INTRODUCTION
2. BALANCING ‘NO BLAME’ AND ACCOUNTABILITY
3. JUST CULTURE
4. HIGH-RELIABILITY AND JUST CULTURE
5. CONCLUSION
CHAPTER 7. JUST CULTURE – WHO DRAWS THE LINE?
1. INTRODUCTION
2. ACCOUNTABLE TO WHOM?
3. POWER AND PERCEPTION
4. WHO DRAWS THE LINE?
5. CONCLUSION
CHAPTER 8. JUST CULTURE – WHAT HAPPENS AFTER THE LINE HAS BEEN DRAWN?
1. INTRODUCTION
2. TWO FORMS OF ACCOUNTABILITY
3. ERROR WISDOM AND FORESIGHT
4. HEALING
5. CONCLUSION
CHAPTER 9. JUST CULTURE – PRACTICAL APPLICATION: LESSONS FROM AVIATION
1. INTRODUCTION
2. EUROPEAN UNION
3. THE INTERNATIONAL CIVIL AVIATION ORGANISATION (ICAO)
4. SOUTH AFRICA – CIVIL AVIATION ACT
5. CONCLUSION
CHAPTER 10. THE FUNCTIONING AND EFFICACY OF THE MEDICAL MALPRACTICE SYSTEM
1. INTRODUCTION
2. THE MALPRACTICE LITIGATION STUDIES – UNCOVERING THE UNDERLYING PATIENT SAFETY PROBLEM
3. FUNCTIONING AND EFFICACY OF THE MALPRACTICE SYSTEM
4. CONCLUSION
CHAPTER 11. THE SOUTH AFRICAN HEALTHCARE SYSTEM – QUALITY AND SAFETY ON THE POLICY AGENDA
1. INTRODUCTION
2. QUALITY AND SAFETY IN SOUTH AFRICA
3. RENEWED FOCUS ON QUALITY
4. CONCLUSION
CHAPTER 12. THE SOUTH AFRICAN HEALTHCARE SYSTEM – THE OFFICE OF HEALTH STANDARDS COMPLIANCE
1. INTRODUCTION
2. NATIONAL HEALTH INSURANCE
3. THE OFFICE OF HEALTH STANDARDS COMPLIANCE
4. CONCLUSION
CHAPTER 13. THE SOUTH AFRICAN HEALTHCARE SYSTEM – THE IDEAL CLINIC AND IMPROVEMENT STRATEGIES
1. INTRODUCTION
2. THE IDEAL CLINIC INITIATIVE
3. IDEAL CLINIC – DOCUMENTS, POLICIES, GUIDELINES AND STANDARD OPERATING PROCEDURES
4. CONCLUSION
CHAPTER 14. THE SOUTH AFRICAN MEDICAL MALPRACTICE SITUATION
1. INTRODUCTION
2. THE EXTENT OF THE CURRENT MEDICAL MALPRACTICE SITUATION
3. PATIENTS PAY THE PRICE
4. CAUSES OF INCREASED MALPRACTICE LITIGATION
5. CONCLUSION
CHAPTER 15. THE SOUTH AFRICAN MALPRACTICE SITUATION – RIPE FOR REFORM?
1. INTRODUCTION
2. THE SOUTH AFRICAN CONTEXT
3. SOUTH AFRICAN LAW REFORM COMMISSION: ISSUE PAPER 33 (PROJECT 141) MEDICOLEGAL CLAIMS
4. CONCLUSION
CHAPTER 16. THE UK EXPERIENCE – AN ILLUSTRATIVE CASE STUDY
1. INTRODUCTION
2. THE CIVIL JUSTICE SYSTEM AND MEDICAL MALPRACTICE
3. THE HEALTH SYSTEM
4. CONCLUSION

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