Blame Research Articles

MEDICAL ERRORS AND PATIENT SAFETY CULTURE – SHIFTING THE HEALTHCARE PARADIGM IN ROMANIAN HOSPITALS

Patient safety (PS) is a global concern of national health systems, defined as the patient s right not to be subjected to unnecessary harm potentially associated with the medical act. Reporting medical errors for learning purpose was deeply encouraged by WHO during the last 10 years, as a mandatory step in preventing future errors and increasing patient safety. Aim. The paper aims to analyze the level of implementation of Patient safety culture (PSC) and reporting adverse events in Romanian hospitals, during 2011-2019, in the context of this globally shifting paradigm in healthcare. Materials and methods. The paper is a review of articles published in international databases conducted by the keywords “patient safety” and “medical errors”. A documentation of the statistical data reported by the national health institutions regarding the reports of EA in different national systems was carried out. Results. Passive reporting of the AEs in the national surveillance systems is on an upward trend, but still low when compared to Western European countries. Several prospective studies, on a limited number of hospitalized patients, showed a prevalence of HAIs 10 times higher than that reported (2,8-5% vs. 0.4%). Similar results were found for reported adverse drug reactions and other adverse events. Missing information about who should report, what should be reported, what are the AEs that are useful for learning purposes, what are the consequences of reporting upon individuals and upon institutions are all important causes of a low rate of reporting. Conclusions. Changing the culture in healthcare is a longstanding process, but the results in recent years are encouraging. The popularization of “no blame culture” and “learning by reporting AEs”, increasing communication and teamwork by hospital management and national healthcare institutions will improve patient safety in Romanian hospitals.

Who’s to blame? These three scientists are at the heart of the Surgisphere COVID-19 scandal

Who’s to blame? These three scientists are at the heart of the Surgisphere COVID-19 scandal

Family dispute resolution and access to justice in Australia

AbstractThe context of this paper is the several innovative reforms since the Australian government changed the family-law system more than forty years ago with the enactment of the Family Law Act 1975 (Cth). Whilst no-fault divorce was introduced over four decades ago, the watershed effect of replacing a blaming culture with a collaborative problem-solving approach to family disputing has provided a stepping stone for a progressive pathway to less adversarialism in family conflict. This narrative resonates throughout the family-law system today. It also continues to guide the justice discourse in family matters. This paper focuses on developments in the family-law system canvassing several legislative amendments that demonstrate the use of alternative dispute resolution (ADR) as a means of improving access to justice in relation to family disputes in Australia. It is argued that, in the family-law system, justice and ADR are inextricably linked. In support of this contention, the growth, development and evaluation of family dispute resolution is considered; access to justice issues that arise are highlighted. Finally, it reviews ramifications for the future considering recommendations from the recent inquiry into the family-law system.

Low use of vacuum extraction: Health care Professionals’ Perspective in a University Hospital, Dar es Salaam

BackgroundUse of vacuum extraction (VE) has been declining in low and middle income countries. At the highest referral hospital Tanzania, 54% of deliveries are performed by caesarean section (CS) and only 0.8% by VE. Use of VE has the potential to reduce CS rates and improve maternal and neonatal outcomes but causes for its low use is not fully explored. MethodDuring November and December of 2017 participatory observations, semi-structured in-depth interviews (n = 29) and focus group discussions (n = 2) were held with midwives, residents and specialists working at the highest referral hospital in Tanzania. Thematic analysis was used to identify rationales for low VE use. FindingsUnstructured and inconsistent clinical teaching structure, interdependent on a fear and blame culture, as well as financial incentives and a lack of structured, adhered to and updated guidelines were identified as rationales for CS instead of VE use. Although all informants showed positivity towards clinical teaching of VE, a subpar communication between clinics and academia was stated as resulting in absent clinical teachers and unaccountable students. ConclusionThis study draws connections between the low use of VE and the inconsistent and unstructured clinical training of VE expressed through the health care providers’ points of view. However, clinical teaching in VE was highly welcomed by the informers which may serve as a good starting point for future interventions.

I Do Not Want to Know, but I Really Curious About the “Blame Look”: An Investigative Approach Towards Consumers’ Responses Utilizing Grounded Theory Methods

I Do Not Want to Know, but I Really Curious About the “Blame Look”: An Investigative Approach Towards Consumers’ Responses Utilizing Grounded Theory Methods

No Blame No Gain? From a No Blame Culture to a Responsibility Culture in Medicine.

Healthcare systems need to consider not only how to prevent error, but how to respond to errors when they occur. In the United Kingdom’s National Health Service, one strand of this latter response is the ‘No Blame Culture’, which draws attention from individuals and towards systems in the process of understanding an error. Defences of the No Blame Culture typically fail to distinguish between blaming someone and holding them responsible. This article argues for a ‘responsibility culture’, where healthcare professionals are held responsible in cases of foreseeable and avoidable errors. We demonstrate how healthcare professionals can justifiably be held responsible for their errors even though they work in challenging circumstances. We then review the idea of ‘responsibility without blame’, applying this to cases of error in healthcare. Sensitive to the undesirable effects of blaming healthcare professionals and to the moral significance of holding individuals accountable, we argue that a responsibility culture has significant advantages over a No Blame Culture due to its capacity to enhance patient safety and support medical professionals in learning from their mistakes, while also recognising and validating the legitimate sense of responsibility that many medical professionals feel following avoidable error, and motivating medical professionals to report errors.

AUTOMATIC GRADE PROMOTION POLICY AND ITS INFLUENCE ON PUPILS’ ACADEMIC ACHIEVEMENT AMONG PUBLIC PRIMARY SCHOOLS IN KIRINYAGA CENTRAL SUB-COUNTY, KENYA

There has been a declining trend in performance among pupils in public primary schools at Kenya Certificate of Primary Education (KCSE) examinations since the introduction of automatic grade policy. The cause of this worrying trend is blamed on, among other factors, the implementation of the policy. The purpose of this study was to establish the influence of automatic grade promotion policy on pupils’ academic performance in Kirinyaga Central Sub-County. Specifically, this study sought to establish; the status of adequacy of physical facilities in primary schools arising from the implementation of automatic grade promotion Policy in Kirinyaga Central Sub County, and the impact of physical facilities on performance of Pupils’ academic performance at KCSE among primary schools in Kirinyaga Central Sub-County. This study used descriptive survey research design and adopted a mixed method approach. The population of the study was 32 head teachers, 181 teachers and 2170 pupils; and a sample of 30 head teachers, 118 teachers and 325 pupils. Purposive sampling technique was used to sample head teachers while simple random sampling was used on the teachers and pupils. Questionnaires were used to collect data from teachers and pupils, while sampled head teachers were interviewed. Questionnaires were piloted in a neighboring Sub County using test retest method and reliable reliability index of 0.702 and 0.756 obtained for teachers’ and pupils’ questionnaires respectively. The questionnaires and interview guide were adequately validated and administered. Quantitative data is tabulated while qualitative data was analyzed thematically in line with the research purpose and to answer the research questions. The study established that there are inadequate physical facilities in primary schools in the study area arising from the implementation of the automatic grade promotion. It further found out that the facilities were not adequately maintained and therefore compromised learners’ health and safety, and hampered instruction. The study concludes that school physical facilities influence pupils’ academic achievement. The study recommends that; government and other stakeholders should provide adequate physical facilities in schools alongside complementary resources for effective implementation of automatic grade promotion policy, schools should institute routine schedule of maintaining the available physical facilities. It further recommends a similar study be carried out in other Counties and to engage a larger population and more variables. Article visualizations:

Did Japan miss its chance to keep the coronavirus in check?

He has become known in Japan as the “80% uncle ” Over the past several weeks, Hokkaido University epidemiologist Hiroshi Nishiura has given innumerable TV and newspaper interviews urging the public to reduce social contact by 80% in order to reverse the suddenly explosive growth of Japan’s COVID-19 epidemic “Cooperate to reduce contacts immediately in a drastic manner,” Nishiura keeps saying He often points to a graph showing results from his modeling indicating that Japan’s outbreak can only be contained if people drastically and immediately limit their interactions with others If they used to have contact with 10 people a day, they have to cut that to two, he says Japan’s government is hoping people will listen Confirmed case numbers remain relatively low, but are rising at an alarming rate On 15 March, Japan had an official cumulative total of 780 cases;as of 19 April, that number had soared to more than 10,700, 3000 of them in Tokyo “Tokyo and other big cities are already entering an explosive phase and other areas in Japan are also following that path,” says Kenji Shibuya, a global health scholar at King’s College London He and others blame a containment strategy that focused on known infection clusters but limited access to testing, allowing individual cases to escape surveillance

Millennials - The Missing Piece in the NHS Workforce Puzzle?

UK healthcare is in the throes of a workforce crisis. There are 10,000 fewer doctors and over 50,000 fewer nurses than are required to run a safe and sustainable service. Multiple factors from removal of nursing bursaries, introduction of university fees, poor working conditions, under-resourcing of healthcare services, unmanageable workloads, learned helplessness of clinical risk and a culture of incivility or blame is driving the workforce of the future away from NHS. Several governmental agencies, arm’s length bodies and trade unions have been grappling with this challenge. A few solutions have been recommended under the new contract for junior doctors, reintroduction of support for nurses and expansion of medical school places, but some are yet to be implemented. NHS leaders continue to support blue-sky thinking in terms of workforce innovations but tend to drag their feet when it comes to adoption. This reluctance by senior clinicians, managers and policy makers may be related to a lack of understanding of the values that drive the millennial generation that most younger healthcare workforce belong to. This article will explore the challenges and solutions from a generational perspective and offer an insight to guide future decision-making.

Erin I Kelly, The Limits of Blame: Rethinking Punishment and Responsibility

Erin I Kelly, <i>The Limits of Blame: Rethinking Punishment and Responsibility</i>

The Hidden Curriculum of an English for Academic Purposes Reform in Chinese Universities

The fundamental challenge in China’s higher education is its bureaucratic governance system; however, it remains untouched after several reforms. The recent Shanghai EAP policy does nothing to challenge the system, but rather, it blames the general English curriculum for failing to prepare students academically. By critically reflect on data from some previous studies, this study discovered that the new EAP curriculum and the policy proposed to replace the general English curriculum harbored a hidden curriculum that tightened the control of knowledge, legitimizing the existing higher education system, and reproducing future academic subalterns. This Shanghai EAP policy is the result of the policymakers’ social mobility struggle as members of a new middle class, together with their accomplices: neoliberalism and neoconservatives. However, resistance and conflict exist in every working context, including the context of Shanghai EAP as justified in the study, despite some of the students’ and the teacher’s resistance being counter-productive.

Impact of surgical complications on the operating surgeon.

The involvement of surgeons in major adverse outcomes can have a negative impact on their personal and professional lives, as well as on patient outcomes. Healthcare professionals involved in such incidents have been referred to as 'second victims'. We designed an online survey to study the impact of operative complications on surgeons' professional and personal lives. An online survey of general, gastrointestinal, hepato-pancreato-biliary and vascular surgeons was conducted using the Twitter feed of the Association of Coloproctology of Great Britain and Ireland, the Association of Surgeons of Great Britain and Ireland and the European Society of Coloproctology over an 8-week period. Questionnaires were completed by 82 participants. Ninety-one per cent of respondents were consultant surgeons, 37% with more than 15years' experience. Eighty-three per cent were colorectal surgeons. The majority of surgeons (95%) reported that their practice had been affected as a result of serious complications and 54% suggested that it had had a negative impact on their family life. Fifty-five per cent of respondents mentioned lack of support in their institution for healthcare professionals involved in adverse outcomes and an existing blame culture. Suggestions for improvement included mentoring (41%), counselling (38%), openness (66%), peer support groups (52%) and human factors training (32%). This survey highlights that the majority of surgeons involved in serious complications are adversely affected. Those involved in the running of surgical services need to improve support for surgeons in the aftermath of such events.

Political Risk Factors on Perfomance of Public Private Partnership Renewable Energy Projects: The Case of Geothermal Renewable Enrgy Projects in Kenya

To solve the problem of limited fiscal funds and demand for energy, PPP has been touted as an effective approach. However political risks have been blamed for failure to attract private investments in equally measure as their developed partners. This article looked at political risks influencing the performance of PPP renewable energy projects in Kenya. The study adopted a pragmatic paradigm and employed a mixed methods approach, correlational and descriptive survey design. Quantitative data was collected by use of a self-administered questionnaire and an interview guide was used to collect qualitative data. A sample size of 263 respondents was drawn from a target population of 769 using the Yamane formula. For descriptive statistics the study used the mean and standard deviation. For inferential statistics the study used Pearson’s Product Moment Correlation (r) and Multiple Regression while the F-tests were used in hypothesis testing. The study established a significant influence of political risks r = 0.572, F (1,205) = 99.771, R2 = 0.327 at p<.05 H0 was rejected. The study concluded that there was a significant influence of political risks on the performance of PPP renewable energy projects in Kenya. Based on this finding the study recommends sustainable political stability.

GI Bleed? Don't Blame the Anticoagulant!

Gastrointestinal (GI) bleeding in patients with atrial fibrillation (AF) on oral anticoagulants (OAC) is not uncommon. In an industry-supported study,

Lung cancer: a potential role for dentists.

Lung cancer is the leading cause of death from cancer worldwide and causes more deaths than breast, colorectal and cervical cancers combined. The five-year survival rate for lung cancer in the UK is approximately 15%. Over many years, lung cancer has failed to attract the attention and resources given to other cancers; it has also been stigmatised by a culture of blame, attributable to the sufferer because of smoking. Anyone can develop lung cancer, and between 15% and 20% of people with this diagnosis have never smoked. Many patients with lung cancer are diagnosed at late stages; therefore, early detection is pivotal to improving their survival. Dentists and their teams could potentially play a role in the public perception, prevention and detection of lung cancer.

The views and experiences of patients and health-care professionals on the disclosure of adverse events: A systematic review and qualitative meta-ethnographic synthesis.

ObjectiveTo synthesize the literature on the views and experiences of patients/family members and health‐care professionals (HCPs) on the disclosure of adverse events.MethodsSystematic review of qualitative studies. Searches were conducted in MEDLINE, Embase, PubMed, CINAHL and PsycINFO. Study quality was evaluated using the Critical Appraisal Skills Programme tool. Qualitative data were analysed using a meta‐ethnographic approach, comprising reciprocal syntheses of ‘patient’ and ‘health‐care professional’ studies, combined to form a lines‐of‐argument synthesis embodying both perspectives.ResultsFifteen studies were included in the final syntheses. The results highlighted that there is a difference in attitudes and expectations between patients and HCPs regarding the disclosure conversation. Patients/family members expressed a need for information, the importance of sincere regret and a promise of improvement. However, HCPs faced several barriers, which hindered appropriate disclosure practices. These included difficulty of disclosure in a blame culture, avoidance of litigation, lack of skills on how to conduct disclosure and inconsistent guidance. A lines‐of‐argument synthesis is presented that identified both the key elements of an ideal disclosure desired by patients and the facilitators for HCPs, which can increase the likelihood of this taking place.ConclusionsAlthough patients/family members and HCPs both advocate disclosure, several barriers prevent HCPs from conducting disclosure effectively. Both groups have different needs for disclosure. To meet patients’ requirements, training on disclosure for HCPs and the development of an open, transparent culture within organizations are potential areas for intervention.

Health workers’ views on audit in maternal and newborn healthcare in LMICs: a qualitative evidence synthesis

To identify and summarise health workers' views on the use of audit as a method to improve the quality of maternal and newborn healthcare in low- and middle-income countries (LMICs). We conducted a qualitative evidence synthesis. PubMed, CINAHL and Global Health databases were searched using keywords, synonyms and MeSH headings for 'audit', 'views' and 'health workers' to find papers that used qualitative methods to explore health workers' views on audit in LMICs. Titles and abstracts were then screened for inclusion. The remaining full-text papers were then screened. The final included papers were quality assessed using the Critical Appraisal Skills Programme tool for qualitative research. Data on audit type and health workers' perceptions were extracted and analysed using thematic synthesis. Nineteen papers were included in the review, most from sub-Saharan Africa. Health workers generally held favourable views of audit and expressed dedication to the process. Similarly, they described positive experiences conducting audit. The main barriers to implementing audit were the presence of a blame culture, inadequate training and the lack of time and resources to conduct audit. Health workers' motivation and dedication to the audit process helped to overcome such barriers. Health workers are dedicated to the process of audit, but must be supported with training, leadership and adequate resources to use it. Decision-makers and technical partners supporting audit should focus on improving audit training and finding ways to conduct audit without requiring too much staff time.

Verbal Autopsy with Participatory Action Research (VAPAR) programme in Mpumalanga, South Africa: protocol for evaluation

IntroductionThere is a growing recognition of the importance of developing learning health systems which can engage all stakeholders in cycles of evidence generation, reflection, action and learning from action to...

Wellbeing initiatives: all things ‘Great-ix’

It is becoming an increasingly common phenomenon for junior doctors to develop poor morale within the workplace. The Academy of Medical Royal Colleges reviewed the reasons for this, which included working in an organisation that is riddled with a blame culture, and working in fear of litigative circumstances.1 The ‘Health for Health Professionals’ (HHP) group is a confidential counselling service available for all doctors in Wales; statistics have shown a sharp rise in the number of self-referrals, with 160 documented between January 2018 and June 2019.2 As part of my role as a chief registrar, I …

Addressing the Medical Errors in the Re-Organized Healthcare in Indonesia.

Medical errors have emerged as an important problem in terms of negative outcomes for patients that can be associated with Healthcare Workers' behaviour. This study aimed to measure the awareness of the main medical issues in the medical personnel of the Ciracas General Hospital, recently opened after the reorganization and enlargement of an existing Primary Healthcare Outpatients Center. A qualitative research (interviews, focus group discussions and direct observations) was conducted on the most frequent errors occurring in daily practice and on the main causes of these errors. The main errors identified by the questioned staff are wrong medications and wrong processes in drug administration, demonstrating the lack of awareness among the staff of the many other causes of medical errors and, consequently, the absence of corrective interventions. There are nine types of errors that the medical staff failed to recognize as medical errors. They feel and refer that they had never heard, seen, or experienced any of the nine medical errors in the inpatient units. The majority of the medical staff have poor knowledge about medical errors. It is essential to foster the growth of patient safety, eliminating the "blaming" culture in order to increase the quality of this institution.