When Silence Threatens Safety: Lessons from the First Canberra Hospital Neurosurgical Inquiry
Journal of Law and Medicine, Vol. 12, No. 1, pp. 112-118, 2004
7 Pages Posted: 21 May 2009
Date Written: May 20, 2004
Despite widespread institutional and professional support, the recommendations of the Bristol Royal Infirmary Inquiry may be insufficient to reduce patient risk from impaired senior medical practitioners. Using the First Inquiry into Neurosurgical Services at the Canberra Hospital as a case study, this article argues that the Bristol-type recommendations - which emphasise reformulation of clinical governance structures, including early reporting of “sentinel events” and compulsory clinical audits – will be ineffective without a reformed institutional ethos that encourages open transparency and respect for those committed to such processes. Such reformulation may need to commence in medical education and involve new strategies including the use of portable digital technology to facilitate self assessment of performance and immediate reporting of adverse incidents. One important lesson from the first Canberra Hospital Neurosurgical Inquiry is that, even with best practice clinical governance standards in place, and a Health Complaints Commissioner with adequate powers to compel the production of evidence, health care quality and safety will be compromised if a negative institutional culture is permitted to persist. How do we initiate the required change? One approach at the Australian National University Medical School has been to design a curriculum in which medical students are taught to understand the mix of conscience, medical ethics, legal and human rights principles that feed into clinical governance pathways to justify the act of “whistle-blowing” when they are frustrated by a negative ethos. It is hoped that this may soon be linked with programmed portable digital technology facilitating self-assessment and incident reporting. Learning when to conciliate, when to consult, when to rely on existing peer-review structures and when to move to external sources of review, involves a complex balancing process that must be taken seriously in medical education. It cannot be left to chance.
Keywords: Whistleblowing, healthcare quality and safety, medical error, adverse incidents, public interest disclosure, hidden curriculum
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