Blame (4) Flashcards
What is the culpability of the system vs the individual when an error occurs?
- person approach
(Reason)
= Unsafe acts (errors) of people at the sharp end
• Unsafe acts arise from faulty mental processes
→forgetfulness, inattention, negligence, carelessness
•Countermeasures directed at reducing unwanted variability of human error
–> appealing to people’s fear: shaming , blaming , litigation
•View errors has moral issues →bad things happen to bad people (just world hypothesis)
What is the culpability of the system vs the individual when an error occurs?
- evaluation of the person approach
(Reason)
- Blaming individuals emotionally more satisfying than targeting institutions
- People= free agents →can choose between safe or unsafe behaviour
- There is uncoupling (sometimes deliberately so the institution won’t suffer)
•By focusing on person we isolate unsafe acts from system context
- 1) Best people make worse mistakes, not only unfortunate few
- 2) mishaps tend to fall into recurrent patterns
- -> If person approach we will not analyse what went wrong
- -> there is also not premeditative analysis which might prevent error from happening in the first place
What is the culpability of the system vs the individual when an error occurs?
- system approach
(Reason)
(humans are fallible, errors are expected even in best organizations)
• Errors = consequences ≠ causes →consequences of upstream systemic factors
• Countermeasures: cannot change human condition → change conditions under which humans work
•System defences: barriers /safeguards common adverse event occurs →how, why did it fail?
What is the culpability of the system vs the individual when an error occurs?
- error management according to the system approach
(Reason)
2 components:
1) Limiting errors will never stop
2) Creating systems better able to tolerate occurring errors
• Does not try to make the person less fallible through fear and pressure
• Establishing reporting culture
▪Detailed analysis of mishaps → free lessons
▪Based on trust not fear
• Comprehensive management programme aimed at several the person, the team, the task
→ good systems = best safeguards
- expect errors to be made → train to recognize and recover
→ good error management = proactive + willing to learn
• Recharge failure sensors + think of new ones → instead of local repairs, change system
What is the culpability of the system vs the individual when an error occurs?
- Swizz chees model
(Reason)
• High tech systems have many defensive layers
→engineered(alarms etc.), people, procedures and administrative controls
o function is to protect (mostly effective but have weaknesses)
Metaphor:
•Ideal world: each defensive layer is intact
•Reality: slices of cheese with holes
• if holes line up → permit a trajectory of hazard and damage victim
•Active failures= unsafe acts committed by people who are in direct contact with the patient or system-short live impact
•Latent conditions: inevitable “resident pathogens” within the system
o Arise from decision made by designers etc. (those were not always by mistake, could also be strategic)
o Two kinds of adverse effect:
▪ can translate into error provoking conditions within the local workplace (time pressure, understaffing etc.)
▪ can create long lasting holes of weakness in the defences (dormant)
- Can be identified and fixed before →proactive risk management
What is the culpability of the system vs the individual when an error occurs?
- SAME –> The Why Questions
(Bogner)
= ask why did an error occur
• 1st order questions: natural thinking
• 2nd order why question: deliberate thinking
• 3rd order why questions: systems approach to determine how error provoking factor occurs
o Thinking about consequences about consequences
–> Think of an example (coffee spot)
What is the culpability of the system vs the individual when an error occurs?
- SAME –> What is it?
(Bogner)
= System approach to medical error (SAME)
–> complex of dynamically interacting elements
- factors with error provoking potential
▪ system may be of different complexity
▪ different elements play a role
(siehe figure)
- Reverse ripple effect = influence from distal to proximal and ultimately impacts the care provider
- Dorsal systems: indirect (company, culture/organization)
- Proximal systems: immediate (social effects on individual)
- SAME analysis does not reflect the factors that actually contributed to the event –> Two major reasons
▪ 1) memory decays overtime
▪ 2) different people=different analysis
What is the culpability of the system vs the individual when an error occurs?
- SAME –> How to asses errors?
(Bogner)
• trying to understand behaviour
–> necessary to first determine how the person experienced the environment, the context of error
• Free text
+ advantage (over questionnaire) does not guide person to pre-believed factors
- factor may be irrelevant to the person experiencing the incident
But in health care people blame themselves
o Con: allows people to act on their tendency to blame themselves or other people for errors involving human activity
o Con: the reporter may consider only the immediate factors and not factors in more distal systems that determine those proximal factors
•The assessment tool for SAME is a variation of the Critical Incident Technique (CIT)
o That technique was effective in identifying error-provoking problems with anaesthesia machines
o The CIT has been modified and used to consider anaesthesia incidents in a number of studies
What is the culpability of the system vs the individual when an error occurs?
- Systematic failure in the medical field
(Bogner)
- the Johns Hopkins Institute named medical error to be the third leading cause of death in the US (only preceded by heart disease and cancer)
- -> medical errors appear quite stable in time and location (two studies)
- however, just saying “to err is human” is not really solving the problem
- there is also not real scientific proof that making errors is an inherent human trait
- -> ergo, we have to look at the system
(AE = adverse event = errors with bad consequences)
What is the culpability of the system vs the individual when an error occurs?
- the presumption of human fallibility
(Bogner)
= expecting error and fallibility to be part of the human nature
–> person approach (not very helpful)
What is neglect?
- ordinary negligence cases
- medical negligence cases
= a breach of duty is established by offering proof that the defendant did not use “reasonable care under the circumstances, that which an ordinarily prudent person would exercise in similar circumstances”
- needs to be judged by an expert of the field
- used to be established if the defendant did not acted like “average practitioner” or “customary
practice” - how ever since trust in medical professionals has declined the standard got stricter
- now the defendant is liable if they “failed to provide reasonable and prudent care”
- -> however, experts usually do not use this standard in their judgment but an even higher one ( they expect perfect care)
- egocentric bias (overestimation of ability)
What is malpractice?
= Negligence becomes malpractice when it is done intentionally.
What is contributory and comparative negligence?
- both take into consideration the plaintiff’s own role/negligence in their injury etc.
- -> might not be allegeable for compensation because was themselves negligent (contributory)
- -> might be only allegeable for part of the compensation because to a degree negligent themselves (comparative)-> comparative is the doctrine mostly practiced in the US
- not applied if someone is suicidal (cannot be expected to be responsible)
- has become more important, more expertise requested by the defence or by the plaintiff’s attorney
How to determine liability?
–> establish negligence etc. + proximate causality + foreseeability
- negligence (siehe andere Karte)
- causality:
= defendant performed act/omission without which event could not have occurred
BUT that’s not enough!! - Proximate causality:
= any original event, which in natural unbroken sequence, produces a particular foreseeable result, without which the result would not have occurred
(so someone can be negligent without being liable!!!) - foreseeability
= established by proof that the defendant, as a person of ordinary intelligence and circumspection, should reasonably have foreseen that their negligent act would imperil others
(difficult to determine in hindsight)
What biases influence juror and judges when evaluating the responsibility in a negligence case?
- general
(except hindsight)
- confirmation bias = if you don’t know what that is by now I cannot help you
- conjunction fallacy = events that are described in more detailed are perceived as more probable although the opposite is true
–> logical example:
Andrea is a human rights advocate and a feminist. (perceived more probable)
Andrea is a human rights advocate. (more probable)
