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 breasts in a patient for whom only a minor operation was actually planned, and of the administration of the wrong medication because it was mixed up. On the surface, the story is about the failure of doctors and nurses. In view of the incredible suffering of the patients affected, these stories have the potential to trigger anger and indignation among the readership. To whom they are directed is clear. Sloppy work by the medical profession and or nursing. But that falls far short of the mark. It seems a bit adventurous to accuse our healthcare professionals of having a lax attitude to work in general. Error prevention is much more about learning from undesirable events. Alexandra Bröhm is therefore right to criticize the inability of the healthcare system in Switzerland to set up a central register for reporting work errors. Such a registry would be the basis for learning systems that could bring about improvements and reduce or completely prevent the occurrence of never events. But even that is not enough. More on this later.

Never Events

In the article, 'never events' are events that should never happen. It need not be mentioned that this term implies an unrealistic hope. We humans are fallible. Much more unfortunate is the fact that the term addresses the result of an event and not the reasons that led to it. But only those are of interest when it comes to making healthcare safer. Dear physicians, 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. It is not about never events! It is about the 'Never Causes'! There must not be certain reasons that lead to an event. That is decisive and only that.

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, physicians and nurses operate in environments that influence them relentlessly. When they perform actions that lead to unintended results, such obstructive influences have always been involved in shaping the situation. But because they are part of history as actors, when they report, they must expect to be sanctioned. Because they will be judged and condemned by people who are not fixated on causes ('Never Causes') but on 'Never Events'.
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 entrust ourselves as patients to the health care system. A medicine that is capable of learning and that continuously reduces the risk of incorrect treatment. I don't know about you. But I definitely prefer the second option.

Punishment prevents learning

I am not surprised to read in a comment of the article by Alexandra Bröhm that the punishment for the guilty 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, she sees only the result. 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 physician can take away from the story 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 make more of an effort from now on, then we are on the wrong track. We have to understand that we are hitting the sack, but we mean the donkey. Today, a substantial part of Swiss healthcare organizations 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 anchored matter of course. Dear decision-makers in the healthcare system, isn't it time to get rid of this incomprehensible deficiency? After all, it is not only about improving patient safety, but also about reputation.

But in all 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 a legal framework that does 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 urging politicians to create the legal framework mentioned above results in 2,000 deaths every 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 to account. It must not be the case that next year, when Parliament deals with the postulate 'Just Culture in Swiss Law', it will once again remain inactive. 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. I also believe that not only the decision-makers in the healthcare sector, but also our parliament are capable of learning.