Over the past two weeks I have recounted the story of a patient who suffered from systemic iatrogenic harm. This harm occurred despite the efforts of a number of attentive professionals who individually delivered comprehensive care. I have argued that with a different perspective the harm may have been foreseeable and therefore avoidable. This week we will examine the responsibility of those involved. Exploring the series of events that led to the harm being undetected. I will argue that the response of the health service is ill-suited to the realities of contemporary health service delivery.
The series of events described in our story took place over forty-eight hours and involved at least four medical officers and six nurses. Each professional acted in a competent manner and responded to the situation at hand. While they all had a responsibility to prevent harm none of these professionals can be held responsible for the harm suffered. This is because the attribution of responsibility is a condition of the ability to foresee undesirable outcomes1. In our story the inability to foresee the outcome was a function of the spread of information throughout the participants. As a result, no one individual can have perfect knowledge of the series of events that lead to the injury. If we are to prevent such events occurring again we must recognise that this is a problem of many hands.
Ibo van de Poel1 conceptualised the problem of many hands as occurring if the collective is morally responsible for the event, but none of the individuals making up the collective can be considered morally responsible for the event. At this point it is tempting to think of moral responsibility as a precursor to the attribution of blame for the purpose of retribution, remediation, and justice. In our story there is no one to blame. There is no evidence to suggest that any of the professionals involved in this case where negligent in exercising their duty of care. However, each individual involved in this case, and the collective as a whole, has a moral responsibility to be forward looking. As health professionals our duty of care to others is a virtuous responsibility. Therefore responsibility must be attributed to reduce the future likelihood of harm.
As a collective (the health service) we have attempted to meet our moral responsibilities. Following the harm the health service undertook a Root Cause Analysis (RCA). A RCA is a retrospective process that attempts to identify causal factors that have contributed to an adverse event. This is achieved by adopting the role of perfect observer; piecing together actions and knowledge to identify a single causative factor. The RCA process is effective in identifying system errors and developing institutional rules to obviate future error. But this only works in groups where there is a clearly articulated aim and agreed parameters for measuring success. Most importantly the rules set as a result of a RCA can only be effective if the aims and criteria for success are accepted by all agents within the organisation. Here is the problem. That is not how contemporary health care works.
Contemporary healthcare is delivered by a collective of individuals who undertake actions organised in an ad-hoc manner. The success or otherwise of those actions depends on the individual needs of the patient and how those needs are interpreted by individual professionals. This is the way it should be. A professional not a functionary. As health professionals our duty of care is a virtuous responsibility. How we interpret the goals of care, and methods we select to achieve aims are derived from mixture of evidence, experience, and resources. We do our best to adapt to imperfect situations, achieving what is possible for our patients. We do this is in loosely organised networks. The process of root cause analysis, with its focus on past causation, is ill-suited to the distributed complexity of health care. We need a forward looking approach. An approach that allows us to think about what actions may be undertaken and what outcomes we may hope to achieve or avoid.
Solving the problem of many hands in health care must take account of professional freedom. Actions and consequences in a distributed network depend on both the choices of individuals, and the capacity of these individuals to cooperate. Policy or protocols derived from RCA findings will fail. Such responses do take account of the freedom and adaptability required in professional work.
Three weeks ago I suggested that we were not rational agents. I stated that there is a need to radically rethink how healthcare decision making is organised. Both of these statements hold true. In the first instance we must begin to conceive of ourselves as nodes in a loosely organised network. Where each node acts on imperfect information. By changing our perspective we begin to appreciate that institutional responses fail to account for the complexity of professional decision making. Our organisations, institutions, hospitals, wards and units should to adapt to how teams of professionals work together. Rather than attempting to force the professional to adapt to the institution. And this is why we must radically rethink how healthcare decision making is organised.
Next week I will discuss the outcome of the Root Cause Analysis and I will propose an alternative way of addressing systemic error.
This article contains information on a critical incident investigation. Names, dates, and some of the details have been removed or changed to protect the identity of those involved.