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A “just culture” is needed if patient safety is to be advanced.
A teenage girl died earlier this year at Duke University Medical Center after a heart-lung transplant when the donor turned out to be ABO incompatible.1 The circumstances were particularly tragic and poignant; the funds for her procedure had been raised by concerned citizens in support of her desperate parents who had taken quite extraordinary steps to save the life of their daughter. The surgeon who requested and accepted the organs assumed that ABO compatibility had been established. The error was detected only after the procedure had been completed. In spite of every effort, life support had to be withdrawn some 2 weeks later when brain death became evident after a second transplant. The response of the hospital and its staff appears to have been exemplary. Responsibility for the disaster was accepted, everyone was kept fully informed, an urgent investigation was undertaken, and measures to prevent a recurrence immediately instituted.1 However, matters were made extraordinarily difficult for all involved, including her family, by an incendiary media frenzy.
In the short time since her tragic death there has been much comment on the events leading to it and on what is needed to prevent this happening again.1–3 But there are also crucial lessons to be learned from the way in which it has been reported and written about. These have wide implications. It would compound the tragedy if the “legacy” of this so public and so unnecessary death resulted in improvements in ensuring organ compatibility but also perpetuated attitudes that hinder significant advances in making health care safer. Five statements that appeared in just one paper illustrate how far we have to go to advance the understanding of safety within health care.
(1) “In the aftermath of such a disaster there must be an assignment of blame”. Errors, by definition, are unintentional and are rarely truly blameworthy.4 Unfortunately, the tort system requires fault to be found and blame to be apportioned for compensation to be awarded, reinforcing the powerful human tendency to apportion blame on the basis of outcome rather than culpability.5,6 The assumption by the surgeon that incompatible organs would not have been offered was, in our view, reasonable, albeit disastrous in hindsight. Blaming—and thereby effectively punishing—well intentioned individuals, whether team leaders or team members, when things go wrong as a result of genuine errors achieves nothing (as acknowledged by Campion2), is unjust, and is usually counterproductive.7 Blaming and punishing is both reasonable and appropriate when a patient is harmed as a result of a violation or deliberately unsafe act, but this does not appear to have been the case here.
(2) “ . . . last month the country heard that things at Duke had gone terribly wrong for no good reason”. There are, in fact, excellent reasons why things go wrong with the present approach to trying to ensure ABO compatibility, whether for blood or for donor organs.8,9 It is currently inevitable that hundreds of ABO incompatibilities slip through the net every year, a substantial number of which result in death. Common errors such as misidentification and mislabelling at ward level, both at the time of taking blood samples and of giving blood (or tissue) can only be truly minimised by the establishment of a completely separate duplicate process, rather than trying to strengthen intrinsically vulnerable links in a single linear chain.
(3) “I am ultimately responsible for the team and for this error”. We suggest that this traditional notion is anachronistic and illogical. While someone must be ultimately responsible for the overall structure and function of any team, this person cannot in reason or justice be responsible for every error made by any member of the team. Transplant surgeons have numerous important tasks to undertake under severe time constraints and it is inappropriate for them to have to divert their finite cognitive resource to ensuring that they personally check every aspect of every process. They should be entitled to rely on other trained professionals to do their jobs properly. Is it reasonable to hold the surgeon responsible if faulty filters or membranes were used in the cardiopulmonary bypass machine, or if a wrong drug was inadvertently used by the anesthesiologist? The problem in this case appears to have been a system failure and it is far from clear that any individual on the transplant team was “to blame”.4,7 The processes used were simply inadequate and, unfortunately, this only became apparent by way of a disaster.
(4) “Her story does not support the cause of strict limits on the damages a jury can award”. Whilst fully acknowledging the exceptional circumstances of this case and the inability of anyone bar her parents to fully appreciate the depth of the resulting grief and devastation, the general thrust of an argument to cap punitive damages should not logically be constrained by the story surrounding her death, however tragic and poignant. If anything, cases such as these provide a strong argument for capping punitive damages—which should only be awarded where genuinely culpable behaviour has occurred. Compensation for loss of earnings is a quite different matter, but probably does not apply to any significant extent in this case.
(5) “Nationally, this tragedy has already weakened the prospects in Congress for malpractice-liability reform”. While this may be the case, it is at least partially because sensationalist media reports promote the unfettered advancement of popular misconceptions about the relationship between error and blame, especially when things that go wrong result in unexpected catastrophic outcomes. Accepting these misconceptions as the basis for what should ensue in the aftermath of a disaster such as this will simply result in “more of the same”. While some may consider that editors in the populist press have a duty to reinforce the prejudices of their readers, we would argue that the opposite should pertain with respect to the mainstream medical press, which should promote a proper understanding of the complex relationships between error, blame, and violations when complex systems fail.
Major initiatives are underway to address the root causes of iatrogenic harm. One important aim is to replace the pervasive “blame culture” in health care with a “just culture”.7 It behoves a journal with a richly deserved reputation for being at the forefront of disseminating research to act as a platform for advancing the complex arguments that must underpin initiatives in the area of patient safety. The statements we have commented upon reflect widely held sentiments. However, we believe that they are not in accordance with current thinking about organisational failure.4,6,7 Unchallenged, when presented in a leading medical journal, they will perpetuate one of the root causes of iatrogenic harm—the blaming of individuals for the tragic consequences of system failures.
A “just culture” is needed if patient safety is to be advanced.
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