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Editors: Paul Hofmann, Frankie Perry
255 pp Price £50; US$90 ISBN 0-521-82900-3 (h/b)
Cambridge: Cambridge University Press .
We are told by one of the contributing authors that ‘King Henry VIII died of syphilis, having never produced a surviving male heir for his throne’, which would have puzzled Edward VI, his son and successor. Who was responsible for this error? According to this book we should look beyond the individual author and consider the ways in which system defects allowed such a mistake to occur; the two academic editors, the proofreader, the production editor, the copy editor and the publisher should all be considered along with the way a book is produced. Analysis of the error should result in self-reflection and changes to the system so that errors are less likely to occur in the future. Naming, blaming and shaming should be avoided. People should view mistakes as learning opportunities. Indeed, very little learning occurs without some mistakes being made.
Over the past decade much attention has been paid to medical errors, with a focus on the activities of clinicians. Little attention has been given to managerial or executive errors, though these can have far greater impact. Managerial errors are often, unlike medical errors, distant from the adverse impact and their effect is therefore more difficult to detect and attribute. Management Mistakes in Healthcare starts to redress the balance. Edited and written by healthcare executives in the US, it is aimed principally at colleagues in that country. While the underlying messages are equally applicable outside the US, the focus on profits, market share and other financial goals means the non-American reader needs to translate the material for health systems that have other drivers and aims.
The book covers the whole field—defining mistakes; classifying and interpreting them; how mistakes evolve; techniques for identifying and disclosing errors; the relationship between clinical and managerial mistakes; and preventing and correcting errors. In addition to chapters considering each of these areas, seven case studies illustrate the issues raised. Two experienced British commentators reflect on the material from a non-US perspective.
Of all the issues raised, the definition of an error is perhaps the most critical. One reason why managerial errors can be hard to recognize is the need to consider acts of omission as much as acts of commission. In addition, standards of performance are less clear than in clinical work. And as with medical errors, what constitutes an error will depend to some extent on the particular circumstances and the perspective adopted. The authors provide a helpful typology with seven types of error—legal; organizational; financial; political; professional; ethical; social; and psychological. While intentional wrongdoing is rightly excluded (as something that needs dealing with in line with other criminal activity), there remains the question of defining managerial negligence. The authors suggest four criteria that all have to be fulfilled for an act to be deemed negligent: the decision taken is one that a reasonable person would consider risky; a bad outcome occurs; risky behaviour is the proximate cause; and a reasonable person would have foreseen the consequences. So, unintended and unforeseeable bad outcomes would not be deemed an error.
While this book is a useful contribution to our thinking about managerial errors, it raises many questions. First, locating the primary responsibility for errors on the system rather than the individual can be taken too far. Presumably there are situations where, despite an excellent organization, individuals fall short of expectations and harm occurs? Always blaming the organization has a suggestion of political correctness about it. While there are good reasons from patients' and payers' points of view to adopt no-fault approaches when bad outcomes occur, there is the danger of creating, in the words of one of the authors, a ‘no-fault paradise’.
Second, if too much attention is focused on the consequences of managers' actions, there is a danger of ‘defensive management’ similar to ‘defensive medicine’. Excessive risk avoidance by managers may harm organizations and be to the detriment of patients. It may also mean that managers working in high-risk areas of healthcare (such as medium secure psychiatric facilities) where ‘mistakes’ are more likely in view of the patients served, will be unfairly criticized. Some means of risk adjustment (similar to that used in comparing clinicians' performance) is needed if we are to avoid creating areas of healthcare provision that deter managers from entering.
Third, there is a close and complex interrelation between managerial and medical errors. Distinguishing between them can be tricky. One American example will be familiar to managers in the British NHS—the impossibility of appointing an additional consultant to reduce waiting times if the existing consultants block the move because they want to protect their personal income. Are the persistent long waiting times (a managerial failing) the fault of the managers, the clinicians or simply ‘the system’? Managers will understandably resent being held responsible for a failing that is not of their making. They are also painfully aware that clinicians can blame them for medical errors: the poor clinical outcome was the result of the managers depriving us of sufficient staff, expensive drugs, etc. This approach can also be used effectively by clinicians to resist changes and challenges to professional boundaries. Shroud-waving remains a potent weapon.
Despite these and other loose ends, this book is a welcome first attempt to redress the balance and start examining managerial errors in the way medical errors have been scrutinized of late. The fact there are areas of ambiguity and uncertainty simply confirms the need for more attention to be paid to this topic.