Behind closed doors: accountability and responsibility in patient care

CPR Quality Officer role to improve CPR quality: A multi-centred international simulation randomised control trial

Background

An out-of-hospital cardiac arrest requires early recognition, prompt and quality clinical interventions, and coordination between different clinicians to improve outcomes. Clinical team leaders and clinical teams have high levels of cognitive burden. We aimed to investigate the effect of a dedicated Cardio-Pulmonary Resuscitation (CPR) Quality Officer role on team performance.

Methods

This multi-centre randomised control trial used simulation in universities from the UK, Poland, and Norway. Student Paramedics participated in out-of-hospital cardiac arrest scenarios before randomisation to either traditional roles or assigning one member as the CPR Quality Officer. The quality of CPR was measured using QCPR® and Advanced Life Support (ALS) elements were evaluated.

Results

In total, 36 teams (108 individuals) participated. CPR quality from the first attempt (72.45%, 95% confidence interval [CI] 64.94 to 79.97) significantly increased after addition of the CPR Quality role (81.14%, 95% CI 74.20 to 88.07, p = 0.045). Improvement was not seen in the control group. The time to first defibrillation had no significant difference in the intervention group between the first attempt (53.77, 95% CI 36.57-70.98) and the second attempt (48.68, 95% CI 31.31-66.05, p = 0.84). The time to manage an obstructive airway in the intervention group showed significant difference (p = 0.006) in the first attempt (168.95, 95% CI 110.54-227.37) compared with the second attempt (136.95, 95% CI 87.03-186.88, p = 0.1).

Conclusion

A dedicated CPR Quality Officer in simulated scenarios improved the quality of CPR compressions without a negative impact on time to first defibrillation, managing the airway, or adherence to local ALS protocols.

Medicolegal Considerations in Multidisciplinary Cancer Care

Health professionals participating in multidisciplinary team (MDT) cancer meetings may not be aware of their medicolegal obligations. This commentary aims to identify medicolegal issues concerning multidisciplinary cancer care and provides recommendations for future implementation. Predominant medicolegal issues related to MDT care were identified in the literature; these include patient consent and privacy at MDT meetings, professional liability, formal expression of dissenting views, and duty of care. Analysis of the literature prioritizes several recommendations for managing these issues. With limited precedent on which to base recommendations, this article identifies the formative evidence that may guide the management of these issues in future MDT practice.

Blame and its consequences for healthcare professionals: response to Tigard

Tigard (2019) suggests that the medical community would benefit from continuing to promote notions of individual responsibility and blame in healthcare settings. In particular, he contends that blame will promote systematic improvement, both on the individual and institutional levels, by increasing the likelihood that the blameworthy party will 'own up' to his or her mistake and apologise. While we agree that communicating regret and offering a genuine apology are critical steps to take when addressing patient harm, the idea that medical professionals should continue to 'take the blame' for medical errors flies in the face of existing science and threatens to do more harm than good. We contrast Dr Tigard's approach with the current literature on blame to promote an alternative strategy that may help to create lasting change in the face of unfortunate error.

Accountability: Challenges to Getting It Right

Patient safety experts debated accountability in health care at the 2014 annual National Patient Safety Foundation Congress. The debate reflected the struggles organizations are facing with ensuring a responsible workforce committed to patient safety versus the need to redesign flawed systems that are error prone. The question, "is it the systems or the individual?" was at issue. This article proposes that it is the wrong question, and the failure to apply patient safety science in clinical practice is contributing to the ambiguity fueling the debate. To transform accountability from a source of confusion to a powerful tool for fulfilling health care's fiduciary responsibility to protect patients from harm, we need to reframe our approach. This article presents the science and strategies to create clarity that will redirect the dialogue from a debate in which accountability resides to one about learning for improvement when adverse events occur.

'What would you do if you were me, doctor?': randomised trial of psychiatrists' personal v. professional perspectives on treatment recommendations

BACKGROUND

If patients are unsure whether a specific treatment is really good for them, they often pose the question, 'What would you do if you were me, doctor?' Patients want their psychiatrists to put themselves in their shoes and not to give a 'standard recommendation'.

AIMS

To study whether this question really leads psychiatrists to reveal their personal preferences.

METHOD

Randomised experimental study with 515 psychiatrists incorporating two decision scenarios (depression scenario: antidepressant v. watchful waiting; schizophrenia scenario: depot v. oral antipsychotic) and three experimental conditions (giving a recommendation to a patient asking, 'What would you do if you were me, doctor?'; giving a regular recommendation to a patient without being asked this question; and imagining being ill and deciding for yourself). Main outcome measures were the treatments chosen or recommended by physicians.

RESULTS

Psychiatrists choosing treatment for themselves predominantly selected other treatments (mostly watchful waiting and oral antipsychotics respectively) than what psychiatrists recommended to patients when asked in the 'regular recommendation role' (i.e. antidepressant and depot respectively). Psychiatrists in the 'what-would-you-do role' gave recommendations similar to the 'regular recommendation role' (depression scenario: χ(2) = 0.12, P = 0.73; schizophrenia scenario: χ(2) = 2.60, P = 0.11) but distinctly different from the 'self role'.

CONCLUSIONS

The question 'What would you do if you were me, doctor?' does not motivate psychiatrists to leave their professional recommendation role and to take a more personal perspective. Psychiatrists should try to find out why individuals are asking this question and, together with the individual, identify the most appropriate treatment option.

Multiple accountabilities in incident reporting and management

In this article, we examine the current and increasing emphasis on accountability and patient safety in health care, focusing on practices of incident reporting and management in New South Wales, Australia. We describe the frames of accountability associated with an incident reporting system, and explore how this system manifests in practice. In contrast to literature that situates incident reporting and local practices as oppositional, we used ethnographic methods to observe the incident management practices of clinical staff in a hospital, and found evidence to characterize this relationship differently. We found that accountability has multiple conceptualizations, and we present three findings that demonstrate how the reporting system and incident management policy are interwoven with local enactments of accountability. We suggest that systematic efforts toward improvement cannot be divorced from the local context, and emphasize the importance of local ecologies of practice in facilitating the meaningful utilization of such incident reporting systems.

Development of student professionalism

In late 2007, the American College of Clinical Pharmacy (ACCP) charged their National StuNet Advisory Committee to formulate tenets of professionalism, with the primary goal of introducing students to essential attitudes and behaviors of professionalism. The committee's list of tenets served as a working document for the development of this White Paper. This collaborative effort of the ACCP Board of Regents and the National StuNet Advisory Committee sought to complement other published documents addressing student professionalism. The purpose of this White Paper is to enhance student understanding of professionalism, emphasizing the importance of the covenantal or "fiducial" relationship between the patient and the pharmacist. This fiducial relationship is the essence of professionalism and is a relationship between the patient and the pharmacist built on trust. This White Paper also outlines the traits of professionalism, which were developed after an extensive review of the literature on professionalism in medicine and pharmacy. The traits of professionalism identified here are responsibility, commitment to excellence, respect for others, honesty and integrity, and care and compassion. It is from these traits that student actions and behaviors should emanate. Students, pharmacy practitioners, and faculty have a responsibility to each other, to society as a whole, and to individual patients whom they serve to ensure that their words and actions uphold the highest standards of professional behavior.

Multidisciplinary care in oncology: medicolegal implications of group decisions

Consensus is growing that multidisciplinary meetings (MDMs) provide the best means of formulating comprehensive treatment plans for patients with cancer. Although many doctors attend MDMs and contribute to the decision-making process, only a few will become involved in a patient's care after the team meeting. Despite this, if a patient was grieved by a decision made in a MDM and wished to recover damages, all doctors present at the meeting would be personally accountable for decisions related to their area of expertise. Doctors should be made aware of the legal implications of their participation in such meetings. A greater awareness of these responsibilities and improved team dynamics should optimise outcomes for patients while limiting exposure of the participants to legal liability. Special attention should be given to providing patients with adequate information in this combined speciality setting.

Rationalising public participation in the health service: the case of research ethics committees

This paper seeks to raise questions about the growing emphasis on public participation in decision-making in the health service. It examines the case study of lay participation on Local Research Ethics Committees (LRECs'). In the light of contested theoretical conceptions of the value of lay participation and an absence of a centrally defined role this paper examines practice. It uses qualitative evidence collected in 45 semi-structured interviews with committee members and observations of twenty committee meetings. It examines members' own conceptualisations of lay involvement and the contributions they are able to make in meetings as a result of these conceptualisations. It concludes that without better-defined roles for lay members on these committees they do not possess the authority or knowledge to challenge the experts' technical rendering of research.

Medical liability insurance and damage caps: getting beyond band aids to substantive systems treatment to improve quality and safety in healthcare

The medical liability crisis is affecting our healthcare system. Medical liability and limited physician and hospital access to malpractice insurance have pushed many providers to leave their states, reduce their services, or simply retire. For many, a labor of love has become an agonizing search for insurance to ensure continued practice in an industry for which they trained eight, fifteen, or even twenty years. Limited insurance and potential liability has also led to defensive medicine, in which providers try to avoid lawsuits by ordering tests, procedures, and anything else that might help protect against liability. Moreover, providers may also attempt to avoid high-risk patients or practices altogether to limit opportunities for lawsuits. Although it is questionable whether these efforts actually help, the provider perception of self-preservation through defensive medicine is undeniable—and providers, like everyone, act on their perceptions.

A system of medical error disclosure

External mandates for medical error disclosure are often justified by potential cost savings, the belief in individual moral obligations in health care, and the concept that patients have rights and providers have responsibilities. Such an approach does not recognise the systems nature of error and outcomes and the important quality role disclosure can play in a system of medical error disclosure. Systems concepts, the patient-provider partnership, and overall quality of care can be enhanced using a system of disclosure that provides for education about the systems nature of error, fulfills the delivery system philosophy of mutual respect, and integrates the patient and his/her family as a partner in the error reduction enterprise. Such a system can result using clear disclosure policies and procedures sensitive to patient and family needs, open communications with concerned, committed, and compassionate system representatives, and use of mediation methods that foster communication, allow for venting, and are flexible in their approach to resolving conflict, including using apology. Although a system may also result in conflict resolution costs, more importantly it may foster and solidify a team approach to reducing errors and promoting patient safety.