Organisational failure: rethinking whistleblowing for tomorrow’s doctors

Abstract

The duty to protect patient welfare underpins undergraduate medical ethics and patient safety teaching. The current syllabus for patient safety emphasises the significance of organisational contribution to healthcare failures. However, the ongoing over-reliance on whistleblowing disproportionately emphasises individual contributions, alongside promoting a culture of blame and defensiveness among practitioners. Diane Vaughan’s ‘Normalisation of Deviance’ (NoD) provides a counterpoise to such individualism, describing how signals of potential danger are collectively misinterpreted and incorporated into the accepted margins of safe operation. NoD is an insidious process that often goes unnoticed, thus minimising the efficacy of whistleblowing as a defence against inevitable disaster. In this paper, we illustrate what can be learnt by greater attention to the collective, organisational contributions to healthcare failings by applying NoD to The Morecambe Bay Investigation. By focusing on a cluster of five ‘serious untoward incidents’ occurring in 2008, we describe a cycle of NoD affecting trust handling of events that allowed poor standards of care to persist for several years, before concluding with a poignant example of the limitations of whistleblowing, whereby the raising of concerns by a senior consultant failed to generate a response at trust board level. We suggest that greater space in medical education is needed to develop a thorough understanding of the cultural and organisational processes that underpin healthcare failures, and that medical education would benefit from integrating the teaching of medical ethics and patient safety to resolve the tension between systems approaches to safety and the individualism of whistleblowing.

Learning from experience: a qualitative study of surgeons’ perspectives on reporting and dealing with serious adverse events

“…Failing in addressing individual or structural factors that may affect transparency around, reporting of and learning from serious adverse events may result in potential ‘collateral damage’ harming both surgeons and patients (see figure 1). Thus, part of moving the cultural shift forward is the recognition of barriers to transparency as a patient safety challenge, hampering both collective learning and individual motivation, engagement and learning 43 84 93. Given these indications, we suggest that hospital management, policy-makers and regulators in the Norwegian healthcare system ‘derandomise’ support and learning systems in medical education and surgical trainee training 52.…”

“…This includes the logic of resilience in healthcare advocating that it is prudent to move away from individualised performance factors as explanatory models for errors in healthcare and encourage more attention to system improvement ‘by viewing medical errors as challenges that must be overcome’ 52 74 81–83. A recent publication illustrates the paradox in the individualised models for errors in healthcare, by highlighting how medical school ethics curriculums in the UK still predominantly emphasise ‘individual action’, even though patient safety literature clearly recognises the collective and organisational contributions to failures in healthcare 84. A multilevel perspective to safety which acknowledges the embedded system complexity may encourage and motivate health professionals to share and discuss adverse events as well as reducing their personal discomfort 8 23 85–91…”

Response to: Correspondence on ‘Organisational failure: rethinking whistleblowing for tomorrow’s doctors’ by Taylor and Goodwin

“…We thank the commentators for their thoughtful engagement with our paper 1. In different ways, they make the same substantial point: our suggested interventions are not enough to solve the problems of organisational failure.…”

Manufacturing safer medics

“…My initial reaction to the question posed by Taylor and Goodwin was like first glimpsing ‘Jaws’: we’re going to need a bigger boat . The authors’ answer makes two important claims: first, that safety should be ethically sourced by better integration between teaching of safety and ethics; second, that teaching should encourage students to think about organisational failure rather than focusing on individual blame and personal responsibility to whistleblow 1…”