Summary of the Patient Safety Conference Oration on October 23rd 2013
By Stephen Bolsin

My argument is that the Hippocratic Oath never effectively discouraged the medical profession from poor medical behaviour, sometimes even on a grand scale like the 2nd World War atrocities on all sides. But medical mistakes were known about and the aphorism about Doctors “burying their mistakes” predated the modern era of Clinical Governance and open disclosure by many decades. Even after the World Medical Association had reasserted the Hippocratic Oath in 1964, when the Tuskagee experiment was revealed 8 years later, along with several other unethical experiments in the US, it became apparent that there was not enough in the old ethical standards to encourage or police the profession to behave well (Chelala 1997; Heintzelman 2003). Thus the Four Principles (Autonomy, Beneficence, Non-maleficence and Justice) were introduced and the new ethical approach of ‘Principlism’ was created to accommodate them (Beauchamp and Childress 1973).

However even with the new Principles it seemed that the medical profession was prone to mistakes and poor behaviour including denying or covering up errors (Bolsin 1998; Bolsin and Barach 2012). One problem with systemic medical error in healthcare is that it is incredibly expensive. Estimates in the US from 2000 indicate that as much as US$17-29 billion each year may be consumed by errors and in the UK NHS £1 billion per annum is wasted on lost bed days alone (Kohn, Corrigan et al. 1999; Vincent, Neale et al. 2001). Consequently reporting and eliminating error could lead to huge cost savings and affordable modern health systems into the future. Thus a new approach may be required and the Virtue Ethics approach of identifying what ‘Virtues’ are desirable for the character of the Medical Professional is one such approach (Oakley 1998). The Four Primary Virtues of reasoning, based on Aristotle’s virtues are Wisdom, Conscience, Courage and Temperance (Moderation), which seem ideal characteristics for doctors to espouse in their work. The question then is will these primary virtues help to address the problems of performance monitoring, incident reporting and open disclosure. The answer is that they will require all of them (especially courage) and the virtues dictate the behaviour.

The second strand of my reasoning is related to the evidence of improved outcomes and reduced costs associated with optimising performance, reporting and correcting adverse events “incidents” in healthcare and then open disclosure of errors when they occur (Kraman and Hamm 1999; Clinton and Obama 2006). The evidence is clear and mounting that adopting programmes, which encourage and lead to these policies being successfully adopted, also leads to reduced healthcare expenditure and better outcomes for patients (Clinton and Obama 2006). Feeding back surgical performance had already produced benefits in cardiac surgery, reducing risk-adjusted mortality rates by 40% in two separate studies (Hannan, Kilburn et al. 1994; O’Connor, Plume et al. 1996).

Furthermore the benefits of adhering to the guidelines of specialist societies is also becoming clearer and the reduced mortality in this context must be attractive to patients as well as the profession (Peterson, Roe et al. 2006). Thus coordinating care properly should be a priority in healthcare as about one third of the errors in the Quality in Australian Healthcare study were attributable to poor communication and coordination of care (Wilson, Harrison et al. 1999).

The third strand relates to our work in Geelong. This has then been to link in the requirement for cutting edge technology to help certainly doctors, but probably all health professionals, to monitor performance, report incidents and then disclose appropriately those incidents leading to patient harm (Bent, Creati et al. 2002; Freestone, Bolsin et al. 2006). Putting them all together led to an improved standard of ethical behaviour in anaesthetic trainees and indicates that ethical behaviour or cultural norms can be impacted by using the right approach and that the cultural change can occur in weeks not generations as some senior medical professionals have suggested (Bolsin, Faunce et al. 2005; Bolsin, Patrick et al. 2005). This ties in with more recent work relating improved system performance with increased computerisation (Amarasingham, Plantinga et al. 2009). Increased interaction with computerised ordering and patient management led to significantly reduced mortality and costs. At the same time the use of checklists in emergency situations has also been tested and improved outcomes demonstrated leading to the notion of increased notification of standardised care paths through mobile computing devices (Haynes, Weiser et al. 2009; Arriaga, Bader et al. 2013).

In summary improving technical support to medical professionals in the context of incident reporting, performance monitoring and outcome assessment will improve ethical behaviour. I believe that this is moving towards a higher standard of ethical behaviour, which approaches a Virtue Ethics approach defining the character of a ‘virtuous’ medical professional. This is an evolution of ethical standards beyond the Hippocratic Oath and the Principlism of the late 20th Century. The result should be more effective, lower cost and higher quality health care.

References

Amarasingham, R., L. Plantinga, et al. (2009). “Clinical Information Technologies & Inpatient Outcomes.” Archives of Internal Medicine 169: 108-114.
Arriaga, A. F., A. M. Bader, et al. (2013). “Simulation-Based Trial of Surgical-Crisis Checklists.” New England Journal of Medicine 368(3): 246-253.
Beauchamp, T. L. and J. F. Childress (1973). Principles of Biomedical Ethics. New York, Oxford University Press.
Bent, P., B. Creati, et al. (2002). “Professional monitoring and critical incident reporting using personal digital assistants.” Med J Aust 177(9): 496-499.
Bolsin, S. and P. Barach (2012). “The role and influence of public reporting of paediatric cardiac care outcome data.” Progress in Paediatric Cardiology 33: 99-101.
Bolsin, S., T. Faunce, et al. (2005). “Practical virtue ethics: healthcare whistleblowing and portable digital technology.” J Med Ethics 31(10): 612-618.
Bolsin, S., A. Patrick, et al. (2005). “New technology to enable personal monitoring and incident reporting can transform professional culture: the potential to favourably impact the future of health care.” Journal of Evaluation in Clinical Practice 11(5): 499-506.
Bolsin, S. N. (1998). “Education & Debate: The Bristol cardiac disaster.” British Medical Journal 317(7172): 1579-80.
Chelala, C. (1997). “Clinton apologises to the survivors of Tuskegee.” The Lancet 349(9064): 1529.
Clinton, H. R. and B. Obama (2006). “Making Patient Safety the Centrepiece of Medical Liability Reform.” N Engl J Med 354(21): 2205-2208.
Freestone, L., S. Bolsin, et al. (2006). “Voluntary incident reporting by anaesthetic trainees in an Australian hospital.” International Journal of Quality in Health Care 18(6): 452-7.
Hannan, E. L., H. Kilburn, et al. (1994). “Improving the outcomes of coronary artery bypass surgery in New York State.” JAMA 271(10): 761-766.
Haynes, A. B., T. G. Weiser, et al. (2009). “A surgical safety checklist to reduce morbidity and mortality in a global population.” N Engl J Med 360: 491-9.
Heintzelman, C. H. (2003). “The Tuskegee Syphilis Study and Its Implications for the 21st Century.” The New Social Worker 10(4).
Kohn, C. T., J. M. Corrigan, et al. (1999). To Err is Human. Building a Safer Health System. Washington, Institute of Medicine: 1-16.
Kraman, S. and G. Hamm (1999). “Risk Management: extreme honesty may be the best policy.” Ann Intern Med 131(12): 963-967.
O’Connor, G. T., S. K. Plume, et al. (1996). “A regional intervention to improve the hospital mortality associated with coronary artery bypass graft surgery. The Northern New England Cardiovascular Disease Study Group.” JAMA 275(11): 841-846.
Oakley, J. (1998). A virtue ethics approach. A Companion to Ethics. Khuse and Singer. Oxford, Blackwell: 86-97.
Peterson, E. D., M. T. Roe, et al. (2006). “Association Between Hospital Process Performance and Outcomes Among Patients With Acute Coronary Syndromes.” JAMA 295(16): 1912-1920.
Vincent, C., G. Neale, et al. (2001). “Adverse events in British hospitals: preliminary retrospective record review.” BMJ 322(7285): 517-519.
Wilson, R. M., B. T. Harrison, et al. (1999). “An analysis of the causes of adverse events from the Quality in Australian Health Care Study.” Medical Journal of Australia 170(9): 411-415.

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