I am a physician and therefore obliged to my patients. I was nurtured on this during my training, and the guiding principles of medical ethics have served as the foundation for my professional life. The three key principles of medical ethics are:
- Respect for patient autonomy and decision making
- The intended actions of beneficence
- Those of non-maleficence*
We must engage our patients in respectful decision-making. We must always act in beneficial ways, carefully explaining risks and benefits, and we must avoid harming patients or putting them at unnecessary risk of harm.
Executives in hospitals, regardless of their own professional backgrounds, also must adhere to these principles, even though these leaders may be far removed from direct patient care. They must create and sustain cultures focused on patient safety as the highest priority. They also should be held responsible when patient safety, as measured by the actions of staff, is not the highest priority.
Case Study
A physician injured his right calf while out running. He developed a sharp pain in this calf, which worsened over the next hour, was associated with swelling and resulted in his toenail beds turning a dusky color. He was taken to a local emergency room with a self-diagnosed impending compartment syndrome, i.e., an obstructive compression of blood vessels and nerves due to swelling, with the potential for permanent destruction of tissues. He needed a prompt evaluation to identify any surgically correctable cause such as a clot, and he was likely to be admitted for observation and leg elevation even if no clot was discovered.
He was promptly placed in a cubicle and then the following, potentially serious missteps in his care ensued:
- He was misidentified, given an ID wristband with another, similarly named patient’s details.
- While the nurse was working with the computer trying to figure out how this had happened, she was not paying any attention to his clinical condition, and his leg was becoming increasingly numb and blue.
- Few of the nurses, technicians and physicians ever washed their hands; one even commenting how inconvenient it was to continually wash as it caused her hands to become dry.
- The radiology technician did not provide gonadal shielding to the patient, even though the CT scan of his leg would extend to mid-thigh and therefore possibly encompass that vulnerable area in radiation scatter.
- The admitting physician did not wash his hands, nor did he cleanse his stethoscope until asked to do so.
- On admission the ward nurse never performed a risk assessment for falls, even though the patient could not bear weight. She returned in the morning with a checklist to complete the process stating “I forgot to do this last night”.
- A walker frame, scheduled to be delivered to the patient’s home on the day of discharge, was not delivered for two more days, despite repeated phone calls.
Fortunately no clot was discovered in his calf and he slowly improved over time as the edema induced swelling in his calf resolved.
About two weeks after discharge, the physician-patient received a telephone call from the hospital enquiring about how he was doing and if he had any comments to make regarding his experiences.
He replied “Are you sitting down?”
The nurse replied “Should I be?”
He replied “Yes, I want to tell you about all the things that were done wrong during my stay in your hospital, all the potentially dangerous things that happened while I was under your care, but first you must promise me something. Promise me that you will not go back to any individuals involved in my care with these concerns. You see, so many things were done incorrectly that there is obviously a safety culture problem in your hospital that is system-wide. I believe in the substitution test. You could have substituted other members of staff into each of the roles of individuals responsible for my care, and quite likely the same missteps would have occurred. Complacency is rampant and members of staff do not realize how dangerous the environment is, nor how dangerous they may be. The lack of a patient safety culture in your hospital bespeaks a lack of leadership committed to patient safety.”
The nurse apologized and promised to share these concerns with hospital leaders.
Patient safety is all about adhering to the principles of medical ethics, of recognizing the obligations of respect for autonomy, beneficence and non-maleficence. There is no room for complacency in this dangerous setting. It is the responsibility of leaders, regardless of their profession, to insist on the highest standards of behavior. Our patients depend on us to get this right each and every time.
Primum non nocere. First, do no harm!
Reference:
* Beauchamp and Childress; Principles Biomedical Ethics, Oxford University Press, 7th edition 2012.