ABSTRACT
The procedures for accident reporting within medicine have developed largely within a confidential environment, where openness with the patient has been discouraged.1 The fault-based approach has been described as reactive to those who make complaints and then seeking to individualize blame by finding an individual to pin it upon. This model disadvantages the complainant by limiting the scope of legitimate complaints to those issues where an individual, rather than the organization, can be shown to be at fault. In addition, because individual reputations and livelihoods are at stake, a fault-based system inevitably adopts a lengthy and expensive investigatory process.2 ‘Disasters’ in medical practice tend to evolve rather than simply occur. A series of failures coincide to create a disaster and the doctor is usually just part of the chain of events.3 Errors are described as an ‘inevitable concomitant of the powerful cognitive processes that have permitted us to extend the limits of human achievement’.4 Gawande recounts a number of examples of mistakes confided to him by respected surgeons:
Consider some other surgical mishaps. In one, a general surgeon left a large metal instrument in a patient’s abdomen, where it tore through the bowel and the wall of the bladder…A cardiac surgeon skipped a small but key step during a heart valve operation, thereby killing the patient. A general surgeon saw a man racked with abdominal pain in the emergency room and, without taking a CT scan, assumed that the man had a kidney stone; eighteen hours later, a scan showed a rupturing abdominal aortic aneurysm, and the patient died not long afterward. …all doctors make terrible mistakes. Consider the cases I’ve just described. I gathered them simply by asking respected surgeons I know – surgeons at top medical schools – to tell me about mistakes they had made just in the past year.5
