Review of processes concerning adverse medical events

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Jonathan Scragg*

I. Introduction

The accountability of medical practitioners in this country has been a topic of considerable public interest for many years. Concerns over the lack of an effective complaints process for 'victims' of the health system have led to a number of government initiatives aimed at improving the situation. The commissioning of 'The Review of Processes Concerning Adverse Medical Events' in November 2000, conducted by Helen Cull QC, represents one of the government's latest attempts to address this issue.1 After approximately four months, the 'Cull Report', which represents the findings of that review, was published on 12 March 2001.2 In broad terms the report achieves three things. First, it identifies a number of significant problems with the current complaints process for adverse medical events in New Zealand. Secondly, it makes a number of recommendations for changes to the organisations involved in the process, such as the Health and Disability Commissioner (HDC), the Director of Proceedings (DP), the Medical Practitioners' Disciplinary Tribunal (MPDT) and the Complaints Review Tribunal (CRT). Finally, the report recommends the establishment of a 'one-stop-shop 'to co-ordinate the investigation of all patient complaints in this country.3

Focus of this paper

Despite the publicity surrounding the release of the Cull Report, there has been a dearth of academic writing commenting upon it.4 This paper aims to fill that void by mounting an in-depth critique of the report.5

There are two components to the paper and they occur concurrently. First, there is a systematic and detailed analysis of Cull's most significant conclusions and recommendations.6 While Cull's proposal for the creation of a single 'portal' through which all patient complaints must pass is supported, many of her other recommendations are rejected. Most notably, the writer rejects Cull's recommendation to compress into one system, the investigation of complaints, discipline of medical practitioners and compensation of aggrieved complainants.

The second component of the paper is a broader consideration of the occurrence of errors in the delivery of health services in this country. The goal of this part of the paper is to highlight the fact that there needs to be a fundamental change in the way medical errors are perceived by society, as it is often inappropriate and counter-productive to apportion blame to front­line personnel for adverse medical events. In such situations, errors must be regarded as consequences not causes.7 Accordingly, true blame for some errors should be focused on systems issues which occur well before front-line personnel become involved in an adverse event. This discussion is of direct relevance to the first aspect of the paper, as it is only once this shift in attitude occurs that a more effective complaints system for adverse medical events will be able to be developed.8

Central to this analysis are the writings of James Reason in the field of human error.9 Although focused on errors in contexts other than health care, Reason's theories on latent errors and systems failures, error detection and prevention and the establishment of a safety culture, can be extrapolated to the health sector. The paper will analyse Reason's theories in relation to three separate topics. First, in considering Cull's recommendation for the mandatory reporting of medical practitioners practising below an acceptable standard, the paper will explore five critical factors identified by Reason which underpin the creation of an effective system of reporting.10 Secondly, Reason's theories on latent errors and systems failures will be considered in conjunction with an analysis of Cull's recommendations made under term of reference 2. This section of the paper is important, as a failure to understand the role that latent errors and systems failures play in the occurrence of adverse events is a barrier to the timely investigation of complaints and to the creation of a robust complaints system.11 Thirdly, Reason's theories on error detection and prevention will be analysed in conjunction with Cull's recommendation that the office of the HDC take on the additional role of auditing the databases of a number of other organisations, such as the Medical Council of New Zealand (MCNZ).12

Error detection and prevention are not considered in depth by Cull. This is unfortunate as they are important elements of an effective complaints process because if the occurrence of errors is reduced through early detection and prevention, the complaints system will have far fewer complaints to process.13

Finally by way of introduction, it is apparent that as a result of Cull's almost exclusive focus on the interests of patients, her report does not consider adequately two other key issues — the role registered medical practitioners (doctors) and systems issues play in adverse medical events. A failure to consider these issues will impede the development of a successful complaints process. This paper will concentrate on doctors because they are a key group of registered health professionals operating in the health sector in New Zealand and the term 'doctors' is readily understood.14 The term 'systems issues' is perhaps less clear. The actions of health policy makers, funders, managers and institutions are all grouped under this heading. Some examples of systems issues may help to explain the term. A lack of funding from the Ministry of Health (MOH) to the District Health Boards (DHBs); poor purchasing decisions by the DHBs; inadequate staffing; poor clinical and/or managerial leadership; administrative problems with computer tracking systems; and facilities problems such as a lack of space in hospitals are all 'systems issues'.

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