DOING THE RIGHT THING

This book is dedicated to all healthcare professionals who did the right thing, when doing the right thing was very, very difficult.1^(pii)

Beginning with the dedication cited above, John Banja, the author of Medical Errors and Medical Narcissism, grabs the reader's attention and never lets go. Errors in medical care are inevitable. Despite the fact that healthcare attracts well-intended, bright, and competent people who subsequently become well-educated and experienced professionals, they remain human and fallible. Additional factors such as technology learning curves, constant change, cost constraints, regulatory burdens, and escalating public expectations make it easier to understand some of the shocking medical errors that appear frequently in the news.

Banja begins by sharing research from the prestigious Institute of Medicine's Quality of Health Care in America project that began in 1998. Its first report, To Err Is Human, cited alarming data about rates of death due to medical error, which the New York Times described as the equivalent of 3 jumbo jets crashing every other day.2 He builds on this evidence, establishing a foundation with an interesting discussion, and definition, of medical error. Citing the current definition of error as what "exceeds ordinary and unreasonable levels of performance," he describes error as an "unwarranted failure of action or judgment to accommodate the standard of care." Furthermore, he cites communication (listening, in particular) and other systemic behaviors as highly influential to performance failures that are typically skill-based, rule-based, or knowledge-based. Banja recognizes and respects the plight of the caregiver, who clearly wants to do the "right thing" but continually runs into obstacles. He states that "well-trained, well-motivated people make errors all the time," in spite of layers of redesign, defensiveness, redundancy, and checking.

Historically, errors have been well-protected secrets. Banja traces the practice of concealing medical errors to the late 1920s. He believes that the way to reduce error is through disclosure, which can open the door to improvement and forgiveness. To date, caring providers have been uniformly discouraged from truthful disclosure, to protect against malpractice suits, although current data have shown the opposite to be true. It is well documented that families of patients who are affected by medical errors are more likely to take legal action when "no answers" or "rude answers" are provided. They are less likely to seek legal action when practitioners express sincere regret for the errors and the subsequent patient outcomes.3 The practice of concealment not only promotes narcissism and blocks opportunities for improvement, it prevents opportunities for forgiveness that are healing for the patient, their family, and the concerned caregivers.

The first part of the book, which is interesting and easy to read, focuses on some of the psychosocial aspects of error (rationalization, narcissism, and forgiveness). Sit back and enjoy this part, but start taking serious notes when you get to the second half of the book, which is devoted to a wide range of remedies offering practical and useful methods. His remedies range from tort reform (including a move from malpractice to no-fault systems), to environmental change (creating blameless and non-punitive practice environments), to ethics education (to drive/facilitate and support ethical behavior). Although some of Banja's remedies apply to individuals and organizations, consider the power of an entire profession of nurses coming together to support the safeguarding of patients and the safeguarding of caregivers so they know that if an error occurs, it can be reported and improvements can be made. In a "full-disclosure" environment, patients and their families can be offered an apology and an opportunity to participate in creating improvements.

One of the remedies that Banja introduces is a method he calls empathic disclosure of medical error. Empathy is incredibly hard to attain when you fear that being empathic can wind up in your being sued. But that is the rub. By focusing on their fear of litigation, the health professional who has committed an error, and is afraid to disclose it, unwittingly fails to realize how the harmed patient or family will experience what's happening. Very often, these people immediately suspect that an error has occurred and want an explanation. So, the health professional who is aware that an error has occurred but tries to conceal it is taking a huge chance that the injured party will not find out. However, if they do, they might go straight to a plaintiff lawyer's office because now they are doubly upset: first by the error, then by the concealment.

Throughout the book the author skillfully holds the reader's attention using a combination of human experience followed by thoroughly researched evidence (even his footnotes are interesting). This is a very important and timely topic and I congratulate the author for having prepared so thoroughly. The book is rich in case studies, research, analysis, and solutions, most of which the reader can easily relate and implement on an individual basis. It should be required reading for anyone who manages staff or takes care of or interacts with patients.

Roey Kirk, MSM, CHE

President, Roey Kirk Associates, Healthcare Management Consultants, Miami, Fla. [email protected]

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