INTRODUCTION

Preventable patient harm is recognised as a very significant health problem throughout the world, giving rise to high human and financial costs1. There has been evidence of such harm for a long time and large studies showing the size of the problem have proliferated over the past quarter of a century2.

Despite this ever-growing body of evidence and calls for action, more than a decade of effort appears to have failed to significantly reduce preventable patient harm across the board. For example, a 2016 estimate of deaths from preventable patient harm places medical error as the third highest cause of death in the USA, behind cardiovascular disease and cancer3. Examples of excellence exist, where there has been a consistent and sustained reduction in preventable patient harm4. However, these tend to be limited in scope and reliant on individual champions. Efforts to expand these have often been less successful. The continued absence of comprehensive concurrent data on preventable patient harm

1 _{Many of the studies documented later in this chapter in tables 1.1 and 1.2 provide support for this}

statement. The costs flowing from adverse events have been studies less, but some illustrative examples are Ehsani JP. Jackson T. Duckett SJ. The incidence and costs of adverse events in Victorian hospital 2003-2004. 2006 Medical Journal of Australia, 5 June, volume 184(11), page 551-555, which showed at that time, an adverse event added $6,826 to each admitted episode and total costs to the hospital of $460.311 million. For an examination of estimates of the full costs associated with adverse events see Runciman WB. Moller J Iatrogenic Injury in Australia – a report prepared by the

Australian Patient Safety Foundation for the National Health Priorities and Quality Branch of the Department of Health and Aged Care of the Commonwealth Government of Australia. August 2001. This study estimated acute hospital costs were less than half the life-time costs of adverse events: see Table 4, page 23. Potential savings from addressing adverse events was estimated as exceeding $2 billion with 5 years. A more recent US study estimated adverse event medical costs as at least $19.5 billion and life time costs possibly $1 trillion annually: Andel C. Davidow SL. Hollander M. Moreno DA. The economics of health care quality and medical errors. 2012 Journal of Health Care Finances, Fall, volume 39(1), pages 39-50.

2 _{See Section C, in this chapter and Tables 1.1 and 1.2 for summaries of a selection of these studies.} 3 _{Makary MA. Daniel M. Medical error – the third leading cause of death in the US. 2016 British}

Medical Journal, 3 May, volume 353, i2139 at doi:

http://dx.doi.org.virtual.anu.edu.au/10.1136/bmj.i2139.

4 _{See eg, Pronovost P. Wachter RM. Progress in patient safety: a glass fuller than it seems. 2014}

American Journal of Medical Quality, volume 29(2), pages 165-169. An excellent example is Pronovost’s Michigan Keystone ICU Project, which has seen 10 year sustained reductions in Central- line Associated Bloodstream infections in the ICU’s in Michigan: Provonost PJ. Watson SR. Goeschel CA. Hyzy RC. Berenholtz SM. Sustaining reductions in central-line associated bloodstream infections in Michigan Intensive Care Units: A 10-year analysis. 2016 American Journal of Medical Quality, volume 31(3), pages 197-202.

Chapter 1 – Preventable Patient Harm

remains a significant barrier to determining progress on known issues, to prioritising areas for action on current data and to promptly ascertaining the nature of emerging problems. Much of the patient safety effort thus far has focussed on the system in which preventable patient harm occurs. This thesis accepts the importance of system factors in the causation and the prevention of harm. However, such a focus appears to have had a limited effect on the widespread prevention of patient harm. A focus on system factors may arguably result in diminished attention being paid to the role of individual people as actors in the

occurrence of preventable patient harm and as agents in the prevention of such harm. In reality, all systems are made up of individuals. Doctors, nurses, administrators, patients are all individuals coming together in healthcare for a specific purpose. Actions of each of these individuals related to preventable patient harm occur in a system and in many cases, the actions constitute the system. In almost all situations involving preventable patient harm, “the system” and the actions of individuals within in it exist in a complex

interrelationship.

Current approaches to patient safety have usually focussed on “the system”. This thesis instead is concerned principally with the conduct of individuals, more specifically doctors, and their actions or inactions that result in preventable patient harm or its prevention. The thesis will look at how doctors understand their own conduct and how their conduct influences and shapes the systems in which they operate. The purpose of looking at the conduct of individuals is not to look for someone to blame in a moral sense. It is rather to explore the reasons why doctors act the way they do in relation to preventable patient harm and to consider how this is deeply linked to their identities as doctors. The thesis also looks at the collective expression of the Doctor Identity in the medical profession, and at the institutional impact this has within hospitals and healthcare.

One of the key hypotheses of this thesis is that the occurrence or risk of patient harm and medical error acts as a fundamental threat to the identity of a doctor and to group identity of the medical profession. Normal human responses to identity threats make it difficult for doctors to recognise and be proactive in relation to these issues. Further, the thesis suggests that alternative public policy options may result from exploring how to reduce the

Chapter 1 – Preventable Patient Harm

psychological impact of threats to individual and group identity, compared to a purely system-focussed paradigm.