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One of the current narratives “us and them” fails to acknowledge that there is no strict dichotomy when it comes to patients and clinicians. Clinicians utilise healthcare services adopting a patient role and patients choose to embark on a clinical career, sometimes influenced by positive or negative experiences in healthcare services.
The philosophy of a “single root cause” has not helped the cause of patient safety as it can be sometimes reductionist. When harm occurs, human psyche seeks solace in finding out a reason driven by the question “why me”. It is not uncommon for the human mind to want to attribute the harm as arising from a unitary source. It is often attributed to a single individual or a group of individuals or sometimes a single organisation. When individuals or organisations are singled out as the root cause of the harm, their previous track record is often forgotten. When the need for retribution drives further course of action, the effects can be devastating for an individual or an organisation as they are vilified and demonised. Individuals can be de-humanised.
I am sure everyone will agree that the reason to investigate incidents of harm is to learn the lesson and prevent or reduce re-occurrence. In that process, individuals or organisations would be held to account for their actions or omissions. Whether it is individual or an organisation, accountability is key. Most clinicians understand professional accountability and in addition carry the burden of guilt when harm occurs to patients, irrespective of their role.
However, an unhelpful narrative emerges when the individual or an organisation is deemed to have caused the harm almost exclusively. Very few would deny the contribution to harm and eventual outcome, when it is the case and would be willing to accept the consequences arising out of professional accountability when the attribution is proportionate.
When we transpose a legal construct to a healthcare setting, we need to ensure that the contextual understanding is not lost. As a forensic psychiatrist, I have seen how medical constructs can be misinterpreted in legal settings without the right language and context. Criminalisation of medical error will increase the fear in the minds of professionals who already feel de-valued.
Whilst healthcare as a sector is risky in itself, we do have ultra high risk specialities with high morbidity and mortality. If we cannot staff them adequately due to blame culture, we would increase the risk infinitesimally.
So let’s get the language and narrative right.
Whether its media, coronial system or judiciary, lets acknowledge that disease causes death and failings in healthcare provision contribute to adverse outcomes. They are contributory and not causal. Lets stop saying a clinician killed the patient – when a recognised medical condition has been the cause of the outcome and the failings of a clinician or an organisation contributory.
My involvement in implementing a Just and Learning culture in Mersey Care NHS Trust began in 2016. During these three years, I have come to realise that distinguishing contribution and causality goes a long way in promoting psychological safety for staff which in turn helps reflection, openness and candour.
Instead of constantly looking in the rear view mirror we have started looking forward with the assurance of accountability. A provider organisation cannot fully achieve this without the collaboration of the wider system.
BMA’s initiative in bringing together all the stakeholders in promoting a culture shift has the potential to spearhead a patient safety resolution. I welcome this as an individual who uses healthcare services, a clinician, a BMA member, a manager and a systems leader. As you can see I don’t believe in unitary roles or reductionist dichotomies.
Arun Chidambaram is deputy medical director of Mersey Care
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