According to H.L. Mencken, all human progress, even in morals, has been the work of men who doubted current moral values.
The Harvard Teaching Hospitals met to discuss what they considered to be "all aspects of an institution’s response to an unanticipated event and to try to develop an evidence-based statement addressing these crucial issues." Their meetings included patients and legal representatives. But they worked within the same framework that already hides crimes and errors. For instance, they put Risk Management in charge in order to ensure confidentiality of the incidents.
The goal of Risk Management departments in hospitals is to defeat patients. They are lawyers whose primary mandate is to protect health care from lawsuits. When things go wrong in medicine, no one in medicine is on the side of patients, but there is no one more against patients than risk management departments. Putting them in charge of patient safety initiatives is perverse. How much more clearly could one show the subjective, self-serving perspective of people in health care than by the fact that they think that Risk Management is the right department to be in charge of patient safety initiatives? But they don't see it that way. They have warm feelings about Risk Management because
"You have to protect yourself from lawsuits."
The extent to which health care believes that is the extent to which the well being of patients is not its first priority. Coupled with that is "You have to be there for the next patient." Put those two sentences together and there is nothing, absolutely nothing, that cannot be rationalized as being in the best interests of patients. No matter how dangerous or unfriendly it might be to an individual patient and/or the entire community of patients, it can be rationalized as being good for them with those two sentences.
It is time to doubt their values.
You don't have to protect yourself from lawsuits. You have to protect patients. When you don't protect patients well enough and they get injured, you have to give them some recourse other than lawsuits if you don't want lawsuits. Currently the way medicine responds to its victims is the equivalent of burning a baby with a hot poker if it cries. Victims of adverse events in medicine know about that hot poker. Health care professionals do not believe it exists. And they are the ones who wield it. That level of self-serving blindness is unacceptable.
If they wanted to know, they would.
they would conduct more autopsies
Too often their incentive is not to know. Knowing can be expensive and disruptive. So they don't know. If there is an accident on a highway, an officer records the time of day, the weather conditions, the location, the makes and models of the cars, etc. We know which intersections and which cars and what weather is the most dangerous. We can instruct motorists, redesign cars, rearrange intersections in accord with the lessons learned. In health care they do the opposite.
In health care, people with an interest in the outcome are supposed to file reports. As Wald and Shojania pointed out in their study, only 2% of adverse events are accurately reported by healthcare workers. The iatrogenic death rate dwarfs the automobile accident mortality rate and yet no one keeps track of essential information about those deaths. They don't even do autopsies most of the time. If healthcare providers honestly had the best interests of patients as their primary interest, they would. Instead information either is not colleted or is collected in ways that minimize awareness of negative outcomes.
Patients try to report many of the problems, but no mechanism exists to enable them to do so. No systematic data are collected on patient and family reports of errors, let alone abuses.
According to JCAHO
the least likely people to report sentinel events are health care workers
If you witnessed a stabbing where you work, you might at least gasp or call for help. Hospital personnel learn not to, among the many things they absorb while learning to fit in. If they do something as small as gasp, they have emitted an "excited utterance." That's the legal term for it. It's a response to a surprise. And it can be used as evidence in court. That's why hospital personnel learn not to do it. In hospitals they don't want a record of adverse events.
People in hospitals learn to make that sure no one accidentally says or does something inadvertently that could create a record, even a mere visual or verbal one by showing alarm or asking a patient if s/he's all right. In medicine a major goal of risk management is to defeat memory and prevent the creation of evidence in order to avoid liability. They don't just have a disinterest in reporting. They have a mandate against it.
Hospitals are full of people who are trained
to respond from a position of liability
Victims of abuse and error in medicine don't even have a phone number to call that will be answered by a human being who is on their side and who knows something. The fact that no one in healthcare has done anything about that says a lot about why patient safety is an issue that needs to addressed by people outside of healthcare who do not share the same conflicts of interest as the people inside healthcare.
According to Michael L. Millenson, in Health Affairs, despite several Institute of Medicine reports about the problems in medicine, there remains within healthcare a refusal to confront providers’ responsibility for the problems. There is a silence of deed—failing to take corrective actions—and of word—failing to discuss the consequences. These silences distort public policy, delay change, and lead to thousands of patient deaths. He says that the Institute of Medicine should stop issuing reports and instead initiate emergency corrective-action comparable to Flexner’s crusade against charlatan medical schools (Millenson 2).
Instead habits become laws. What people are used to comes to be seen as what is normal and then what is right. Habits formed by self-interested professionals trying to build careers gain an inertia that stands in the way of making the corrections necessary to save lives.