In much of the medical literature, preventable patient harm is called by the technical term “adverse event”, which was used in the various retrospective medical record review studies discussed below. In general, this term is defined as:
an unintended injury or complication which results in disability, death or prolonged hospital stay and is caused by healthcare management.5
The term has come to be used more broadly in medicine and the patient safety policy discourse as synonymous with unexpected patient harm. In this thesis, the term “adverse event” is used in the description of the various study results to ensure that the technical role of the phrase in these studies is honoured. However, its use is limited to this context because, as a term, I believe it creates ambiguity for most readers and its apparent
“conceptual emptiness” serves to disguise what is being discussed in the public discourse about patient harm.
This thesis argues that the culture of medicine is derived from the beliefs and cultural understandings of individual doctors about their role and their identity. In turn, it is argued that this can act as an impediment to patient safety, through powerful cultural stories that are harm-denying, harm-excusing and in the end, harm-tolerant. In such a context, it is understandable that the phrase “adverse event” was not limited to these studies, but found broad acceptance in medicine. It is a phrase which, at first glance, is not connected to a person at all, as either a causal vector or as someone harmed. The apparently benign and impersonal phrase hides its formal definition and what is being discussed. Many patients and some doctors are not aware of the formal meaning of the phrase used in the various studies: that is, preventable harm to a patient caused by people and processes designed to
5 Wilson RMcL. Runciman WB. Gibberd RW. Harrison BT. Newby L. Hamilton JD. The Quality in
Australian Health Care Study. 1995 Medical Journal of Australia, volume 163, pages 458-471: at page 459 (Grey Box).
Chapter 1 – Preventable Patient Harm
provide healthcare, and which results in the patient’s death, disability or a prolonged hospital stay.
Language can connect or disconnect actions and consequences. While sometimes euphemistic language can be used to be less emotive or to appear more objective, it may also result in a disconnection from ethical or moral meanings. This in turn can impact on how someone engages with issues that may require an exercise of their moral agency (that is, their internal incentive to do the “right” thing).6.
In the development of a moral or ethical self, human beings adopt standards of right and wrong that serve as guides and deterrents for conduct. In this self-regulatory process, people monitor their conduct and the conditions under which it occurs, judge it relation to their personal, moral or social values and perceived circumstances, and regulate their actions by the consequences they apply to themselves. They do things that give them satisfaction and a sense of self-worth, and they refrain from behaving in ways that violate their personal and social standards because such conduct will bring self-condemnation7 or condemnation from peers or their community8. A strong positive professional and ethical norm in medicine is to do no harm to patients. The language of “adverse events”
camouflages the occurrence of patient harm, by hiding the object of the harm and the agent(s) of it. Instead of the term overtly triggering a doctor’s self-regulatory system to want to stop this harm occurring, the language of “adverse events” can fail to trigger the self-regulatory system at all. The agentless passive voice also creates the appearance that negative acts, omissions or outcomes are the work of nameless forces rather than people.9 In medicine when an “adverse event” is said to have occurred in medicine, the term “adverse event” can obscure the meaning of what has occurred not only to the patient but
6 Bandura A. Barbaranelli C. Caprara GV. Pastorelli C. Mechanisms of moral disengagement in the
exercise of moral agency. 1996 Journal of Personality and Social Psychology, volume 71(2), pages 364-374: see page 364.
7 Bandura A. Selective exercise of moral agency. Chapter in Thorkildsen TA. Walberg HJ. (editors)
Nurturing morality. 2004 Kluwer Academic, Boston, pages 37-57: at page 37.
8 Harris N. Reassessing the dimensionality of the moral emotions. 2003 British Journal of Psychology,
volume 94(4), pages 457-473.
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also to the doctor. For example, the likely impact on a doctor’s moral agency of the thought that “An adverse event occurred in the operating theatre”, will be different from that of thinking “The patient I was operating on today died when I accidentally cut his aorta”. While it is also arguable that euphemistic language is used to protect grieving families, the phrase “adverse event” provides little useful information for them and they may see it as the doctor or hospital “hiding” something10. The doctor may feel that the adverse event explanation has discharged any ethical obligation to explain why the death or unexpected patient outcome occurred or the circumstances surrounding it11. A 2006 study by Iedema and others of the language of critical incident reporting provides examples of various degrees of minimisation and distancing.12
An “adverse event” explanation may also leave the patient’s family bewildered because they don’t know what it means. Sometimes they may fear that things are being hidden from them13. Alternatively, language which reduces their understanding of what actually
occurred can mean they remain unaware of the contribution healthcare made to the harm done to their loved one. If they do not understand that the death or harm was preventable and caused by healthcare, they may also be unable to take any action to address their needs eg to complain or seek compensation, where appropriate14.
10 Gallagher TH. Waterman AD. Ebers AG. Fraser VJ. Levinson W. Patients’ and Physicians’ attitudes
regarding the disclosure of medical errors. 2003 Journal of the American Medical Association, 26 February, volume 289(8), pages 1001-1007: at page 1003.
11 Gallagher TH. et al 2003 - see note 10: the results of this study showed that doctors “disclosed the
adverse event” but “avoided stating that an error occurred, why the error happened, and how recurrences could be prevented” all of which were matters that patients saw as vital to proper disclosure. See results section and Tables 2, page 1003, comparing the views of doctors and patients.
12 Iedema R. Flabouris A. Grant S. Jorm C. Narrativizing errors of care: critical incident reporting in
clinical practice. 2006 Social Science and Medicine, volume 62, pages 134-144: see especially, ‘Analyzing critical incident reports’, incident #27 at page 138.
13 Iedema R. Sorensen R. Manias E. Tuckett A. Piper D. Mallock N. Williams A. Jorm C. Patients’ and
family members’ experiences of open disclosure following adverse events. 2008 International Journal of Quality in Healthcare, volume 20(6), pages 421-432.
14 The 1984 Harvard Medical Practice Study showed, among other things, that there was a significant
mismatch between cases of adverse events involving medical negligence and litigation. The ratio of incidence of negligent adverse events to litigation was 7.6 to 1. However, when those cases where litigation was initiated were compared to cases where negligence had been found on medical record review, the difference was even greater, with the majority of cases where litigation commenced not being found to show negligence. Only 1.53% of cases of negligent care resulted in a claim. Localio RA. Lawthers AG. Brennan TA. Laird NM. Hebert LE. Petersen LM. Newhouse JP. Weiler PC. Hiatt HH. Relation between malpractice claims and adverse events due to negligence – results of the
Chapter 1 – Preventable Patient Harm
Therefore, in this thesis, I will generally use the phrases “preventable patient harm” and “patient harm”. This terminology brings together the concepts in the “adverse event” definition in a phrase which is likely to be understood more readily in the public discourse around patient safety. The phrases seek to label the issues of concern in this thesis more openly. The thesis is concerned with the impact of actions and inaction in healthcare by doctors on patients, who are users and consumers of its services. It is concerned with harm to these people – whether it be death, disability or prolongation of incapacity. Its special concern is where this negative impact on a patient is already known to be preventable. However, as will be noted at different points, all unexpected patient outcomes need to be detected and reflected upon, whether the consequences are known to be preventable or not, and sometimes this term will be used.