Culpability in healthcare failures: shifting away from the individual

By Daniel Taylor and Dawn Goodwin

Why do we still search for individuals to blame when things go wrong in healthcare? Decades of research, healthcare ‘scandals’ and their inquiries, and current guidance on patient safety tell us to focus less on the individual and more on the organisational factors that predispose practitioners to error or poor care. A ‘systems approach’ shifts emphasis away from the individual, and follows in the footsteps of other safety-critical industries such as aerospace engineering. However, when the stakes are high and patients have been seriously harmed, the quest for accountability tends to focus our attention on actions of individual practitioners.

Barriers to truly adopting a systems approach in current practice goes as far back as medical school, where students begin to take on the professional identity of a doctor and learn that, irrespective of the organisational context, they alone are responsible for their actions.  And where medical students see mistakes, lapses in judgement or persistent failures in care, they are repeatedly taught they have a moral and professional obligation to raise their concerns or ‘blow the whistle’ if they feel patient safety is at risk. The mere mention of whistleblowing is enough to strike fear into medical students, conjuring up high-profile stories of clinicians such as Stephen Bolsin and Peter Duffy, whose concerns were vindicated in the end, but their professional reputations and personal lives were irreparably damaged in the process of raising their concerns. Such emphasis on whistleblowing overshadows learning on systems approaches and perpetuates a blame culture within healthcare that remains evident today.

But what can we do to combat this issue? In our article, we apply Diane Vaughan’s theory of ‘Normalisation of Deviance’ to an infamous failure of NHS care: The Morecambe Bay Investigation. This analysis highlights some of the key limitations in today’s whistleblowing practices; where the raising of concerns by an obstetric consultant failed to remedy dangerous standards of care. We go back to where it all starts for medical students and suggest that the way we teach students about patient safety and whistleblowing should change.

While our analysis largely focuses on the organisational level, various commentaries on our article have argued that the problems are broader and deeper.  Underfunding, short staffing, a disenchanted workforce and a culture of denial are said to be systemic issues pervasive throughout the national health service. While these are all causes for concern, we argue they can and do exist alongside organisational level factors. The problems that threaten patient safety are complex and difficult to fully comprehend, it cannot be tackled in one fell-swoop. Instead it should be broken down and addressed in more manageable chunks.

In some ways, our work raises more questions than it answers. While we may assert it has at least shed light on some factors contributing to the events of Morecambe Bay, it opens up many more questions about other healthcare failures and how to tackle these factors in medical schools. We suggest starting with students’ understanding of how concerns are assimilated, analysed and acted upon, with curricular reform tailored to these findings. On reading this blog post and/or our full article, you may have your own thoughts on the issues we raise and how to address them. If so, we’d love to hear from you!

 

Paper title: Organisational failure: rethinking whistleblowing for tomorrow’s doctors         FREE

Authors: Daniel Taylor and Dawn Goodwin

Affiliations: Lancaster Medical School, Faculty of Health and Medicine, Lancaster University

Competing interests: None declared

Social media accounts of post author(s): Twitter: @DrDanielJTaylor and @DawnGoodwin12

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