By Dr. Fiaz Maqbool Fazili
Modern medicine emphasizes a culture of learning from mistakes to enhance patient care and safety. This principle is encapsulated in the motto “No Name, No Blame, No Shame,” which seeks to foster open discussions about errors during mortality and morbidity (M&M) meetings. These meetings aim to conduct honest root cause analyses (RCAs) without fear of retribution, enabling healthcare professionals to ask crucial questions: Could we have done better? How can we prevent this from happening again?
However, when mortality and morbidity persist despite such analyses, it raises a critical red flag about systemic issues within the organization. The situation becomes even more alarming when adverse events, no-events, or sentinel events occur—cases such as a patient developing hoarseness after a neck operation, paraplegia following two surgeries, or incidents where a gauze or instrument is inadvertently left in a surgical wound. These situations demand professional scrutiny and accountability.
The Case for Accountability in Medicine
Is anyone supervising private or corporate hospitals?
Healthcare is founded on the principle of primum non nocere (first, do no harm). When a patient walks into a hospital independently but leaves with a life-altering disability like paraplegia, it is not just a tragedy for the patient but also a serious indictment of the healthcare system. Such incidents demand answers to questions like:
1. Was the surgery necessary?
2. Were the risks communicated effectively to the patient?
3. Was there a deviation from standard protocols?
4. What was the surgeon’s recent track record regarding patient outcomes?
In such cases, accountability must extend beyond the individual practitioner to include the healthcare institution, oversight bodies like the Jammu and Kashmir Medical Commission (JKMC), and policymakers responsible for ensuring patient safety and quality standards.
Root Cause Analysis: Identifying Systemic Failures
Root cause analysis (RCA) is a powerful tool for uncovering the underlying reasons behind adverse events. However, for RCA to be effective, it must:
a) Include multidisciplinary teams: Physicians, nurses, administrators, and patient safety officers should collaborate to analyze all dimensions of the event.
b) Investigate systemic issues: Factors such as understaffing, inadequate training, equipment failure, and poor communication must be evaluated.
c) Focus on data-driven insights: Mortality and morbidity trends, complication rates, and near-miss incidents should be meticulously analyzed to identify patterns.
When RCA reveals recurring errors or preventable outcomes, it points to deeper systemic issues such as:
1)Inadequate Training: Surgeons with outdated skills or limited experience in specific procedures pose risks to patients.
2)Weak Oversight Mechanisms: Ineffective monitoring by medical commissions allows unsafe practices to persist.
3)Lack of Standardized Protocols: Variability in treatment approaches increases the likelihood of errors.
The Role of Medical Commissions and Regulatory Bodies
The Jammu and Kashmir Medical Commission (JKMC) is tasked with upholding the safety and quality of healthcare services. However, questions arise about its effectiveness in ensuring accountability. Is the commission conducting regular audits? Are hospitals required to report adverse events transparently? Is there a mechanism to suspend or retrain healthcare professionals with poor track records?
The JKMC must embrace a more proactive role, including:
1. Implementing mandatory reporting: Hospitals should be required to report all major complications, sentinel events, and near misses to the commission.
2. Conducting independent investigations: In cases of severe adverse events, independent probes led by external experts must be conducted to ensure impartiality.
3. Ensuring transparent outcomes: The findings of investigations and the corrective actions taken must be communicated to the public to restore trust.
Organizational Culture: Moving Beyond a Blame-Free Approach
While the “No Name, No Blame, No Shame” approach fosters openness, it should not absolve individuals or organizations of responsibility.
The following principles should guide accountability:
Distinguish Between Human Error and Negligence: Honest mistakes should be met with education and support, but gross negligence or willful misconduct must lead to disciplinary action.
Establish Clear Accountability Frameworks: Each healthcare professional and administrator must understand their role in ensuring patient safety.
Promote a Just Culture: A balance must be struck between learning from errors and holding individuals accountable for repeated unsafe practices.
Building a Safer Healthcare System
To address the recurring issues of mortality and morbidity, healthcare organizations must adopt a holistic approach:
1. Mandatory Morbidity and Mortality Meetings: Standardized across all departments, with outcomes feeding into broader organizational learning.
2. Robust Credentialing Processes: Surgeons and healthcare professionals should undergo periodic evaluations to ensure their skills remain current.
3. Investment in Technology: Advanced monitoring systems, electronic health records, and simulation-based training can reduce errors and improve patient outcomes.
4. Public Accountability: Institutions must publish annual reports detailing patient outcomes, safety initiatives, and corrective actions taken.
The Role of Society and Government
Ensuring healthcare safety is a shared responsibility. While hospitals and regulatory bodies must lead the charge, society and the government have pivotal roles to play:
1. Government Oversight: Strengthen laws and regulations governing healthcare accountability and impose penalties for non-compliance.
2. Public Awareness: Educate citizens about their rights as patients and the importance of seeking care from accredited institutions.
3. Support for Healthcare Workers: Address burnout and staffing shortages, which are significant contributors to errors.
The absence of an Occurrence Variance Reporting (OVR) system in our hospital setup exacerbates these alarming situations. Without such a system, there is no structured mechanism to report, analyze, and address errors or sentinel events.
The tragedy of a patient walking into a hospital on her own but leaving with the loss of voice, paraplegia, or succumbing to simple heart surgeries is a wake-up call. It underscores the urgent need for accountability, professional probes, and systemic reforms.
“No Name, No Blame, No Shame” is a vital first step, but it must evolve into a culture of responsibility and continuous improvement. Only then can we ensure that every patient who entrusts their life to the healthcare system receives the safe, compassionate care they deserve.
Note:
Dr. Fiaz Maqbool Fazili is a medical doctor at Mubarak Hospital, a clinical auditor, and an expert on healthcare quality and patient safety. He can be reached at drfiazfazili@gmail.com and on Twitter @drfiazfazili.
