Call to account

A recent plane trip provided me with an opportunity for some uninterrupted time to catch up on my medical reading. Two apparently unrelated articles were particularly intriguing.

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By  Dr Robert Thurer Published  September 27, 2006

A recent plane trip provided me with an opportunity for some uninterrupted time to catch up on my medical reading. Two apparently unrelated articles were particularly intriguing.

The first column, A Piece of My Mind in JAMA, recounted in a touching way the experiences of a physician-parent coping with his daughter’s leukemia. In this story, Hecht recounts detecting and intervening to correct both a serious medication error and an overlooked liver function abnormality during her treatment. One cannot be anything but shocked that these problems continue to plague the most advanced medical system in the world.

The second article by a Harvard colleague in The New England Journal of Medicine also dealt with patient safety but from a different perspective. In a Perspective piece, Donald Goldman discusses the role of personal acountability in preventing the spread of nosocomial infection.

As Goldman points out, current dogma in patient safety (whether in preventing medical error or controlling hospital acquired infections) is that “complex, error-prone systems are at the root of most mistakes in healthcare”.

This point of view puts forth the notion that well-intentioned providers are often ‘trapped’ into committing errors or performing poorly by inadequately designed systems.

The goal of root cause analysis is to uncover and correct these system failures. To quote Goldman further; “This orientation toward improving systems rather than blaming people who make mistakes is critical, since it encourages caregivers to report adverse events and near misses that might be preventable in the future.”

These ideas are an outgrowth of safety programs developed by the airline industry. So far, so good. Goldman, however, takes his argument further. He points out that personal accountability is also an important element in patient safety.

Using his example, the provider who fails to wash his or her hands between patient encounters is personally responsible for failing to prevent the spread of infection.

While the “system” has the responsibility to provide the sink, soap and disposable towel (or antiseptic solution), the provider has to be responsible for performing proper hand washing.

Analogously, while the “system” must be designed to accurately report and even highlight abnormal laboratory results in a timely fashion, the provider is responsible for interpreting and acting on those reports. Failure to follow properly designed systems should be treated as a “violation” with personal consequences rather than as a “system failure.”

While such thinking may not be as glamorous as the language of root cause and systems design, it is reassuring to know that personal responsibility and accountability still count.

As we care for patients, teach students, interact with colleagues, participate in research and perform the countless daily tasks that make up a modern medical practice, we cannot forget the importance of those core principles that contribute to our shared value of professionalism.

Educators around the world have identified the development of professionalism as a core competency. It’s good to know that it counts.

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