Wrong eye operated

The health care system struggles with malpractice stories that come out in the open. They are unflattering stories, not only because they involve patient suffering, but because they are too often not used for learning. What's at the heart of it?

Yesterday, journalist Alexandra Bröhm from the Tages Anzeiger addressed the readership with an article that gives us insight into a dark and unattractive side of our society. A society that prefers to punish mistakes rather than learn from them.

She tells of operations on the wrong eye, of the amputation of two of a patient's breasts when actually only a minor operation had been planned, and of wrong medication being administered because it had been mixed up. On the surface, the story is about the failure of doctors and nurses. In view of the unheard-of suffering of the patients affected, these stories have the potential to trigger anger, indignation and outrage among the readership. To whom they are directed is clear. Sloppy work by doctors and nurses. But that falls far short of the mark. Alexandra Bröhm is therefore right to criticize the inability of the Swiss healthcare system to set up a central register for reports of work errors and honest mistakes.  Such a register would be the basis for learning systems that could bring about improvements and reduce or completely prevent the occurrence of 'never events'. But even this falls short. More on this later.

Never Events

In this article, 'never events' are events that should never happen. It is not necessary to mention that there is an unrealistic hope inherent in this term. Unfortunately humans are fallible. Much more unfortunate is the fact that the term addresses the outcome of an event and not the causes that led to it. But only those are of interest when it comes to making healthcare safer. Dear doctors, dear nurses, dear patient safety experts or whoever may have brought the term 'never event' into play: please detach yourselves from it. It leads in the wrong direction and stirs up emotions, rage, and anger. It is not about the Never Events! It is about the 'Never Causes'! There must not be certain cause that leads to an occurrence. That is essential and only that. It is about causes such as intent, gross violations of rules or best practices that we as a society should not accept. Causes that we condemn and impose sanctions on, even if they do not lead to harm.

Humans are always integrated into a system and exposed to influences.

Only by focusing on the causes can we see all the contextual influences that promote or trigger an event. Similar packaging for drugs with different effects, poorly set up work processes, time pressure, lack of resources and much more. In their work, doctors and nurses operate in environments that influence them relentlessly. When they perform actions that lead to unintended outcomes, such obstructive influences have always been involved in shaping the situation. But because they are part of the story as actors, when they report, they must expect to be sanctioned. This is because they are being judged and condemned by people who are not fixated on causes ('Never Causes') but on 'Never Events'. Isn't that what we all are over and over again?

It is this unfortunate hard-wired mental process with its focus on the outcome that clouds our view of the causes. It is one of the reasons that reporting systems are not built and maintained. Reporting systems that protect the reporters and that are dedicated to finding the causes. The unreflective and usually unjust personification of cause has led to our criminal law and our sense of justice. We should rethink this and ask ourselves what is more important to us. The punishment of the actors or the good feeling of being able to trust the health care system as a patient. Knowing that it is capable of learning and that the risk of incorrect treatment is continuously reduced. I don't know about you. But I definitely like the second option better.

Punishment prevents learning

I am not surprised to read in a comment of Alexandra Bröhm's article that the punishment for the errant doctor who wrongly and unnecessarily amputated two breasts was shamefully low. Not a word does the commentator ask about the reasons for what happened. Like a mouse hypnotized by the snake's gaze, he only sees the outcome. It is terrible, no question. But the doctor's punishment has done much greater damage. It has prevented learning and left in place the danger that the same mistake can happen again and again, multiplying the suffering instead of reducing it. The only thing the unfortunate doctor can take away from the battle as a rational lesson is: silence is indeed golden.

If we live up to the mistaken belief that things will change for the better in the healthcare system with an emphatic appeal to all doctors and nurses to please try harder from now on, then we are barking up the wrong tree. We have to understand that we are hitting the sack, but we mean the donkey. A substantial part of Swiss healthcare organizations today still do not have a management system that records and analyzes events and reduces risk with adequate measures. In aviation, these management systems are not only required by regulation, but have become a culturally embedded matter of course. Dear decision-makers in the healthcare system, would it not be time to rid yourself of this incomprehensible deficiency? After all, it is not only about improving patient safety, but also about reputation. If you like, we can talk about it.

But in all of this, we must not overlook one thing. Criticism of the players in the health care system falls short of what is required of us as citizens. We are in fact allowing legal framework conditions that do not allow healthcare institutions in Switzerland to protect their reporters from criminal consequences in connection with work errors. Therefore, we should not be surprised if the actors remain silent and the healthcare system does not make any progress in this area.

Politics has a responsibility

According to an estimate by the Federal Office of Public Health, our direct-democratic inactivity in emphatically demanding the aforementioned legal framework from politicians causes 2000 deaths each year. People who died because of avoidable errors and complications. Outrage and appeals are of little use here. We are called upon to hold our politicians accountable. It must not be that the parliament fails again next year when it deals with the postulate 'Just Culture in Swiss law'. If it once again deals with the issue from the traditional perspective, which is characterized by the outdated stimulus-response model: where there is error, there must be punishment. I, at least, assume that we can expect our elected representatives to think in somewhat more sophisticated contexts. Likewise, I believe that not only the decision-makers in the healthcare sector, but also our parliament is capable of learning.