Do Patients Want to Punish?

There is a great debate set forth in the IHI’s Open School discussion of the wrong-side surgery case that  occurred at our hospital a few years ago. (I have written about this below, but there are some new postings.)

Kimberlee Ziga writes: I, as an RN working in an ICU, have also made mistakes. Thank God they have not been life threatening but nonetheless, they were mistakes. I was educated thoroughly and proven to be competent with testing. When I made that mistake, I was written up. I totally understood why. I am a licensed professional who is competent at her job, and that calls for accountability and responsibility. I believe all the medical staff involved should have been held accountable and disciplined accordingly. If that was my family member, I would have been irate for what they had to go through.

In contrast, Jessie Moon says: Paul Levy . . . made it out like it was a serious situation, but one that could happen to any surgery team. He* did not punish any one person, but instead he took care of the situation by asking, “how can we lower the chances of this ever happening again”, which makes the person and the family that this happened to feel better (or so I would assume), the public, as well as the workers in this hospital.

There are two parts to this question. What is the most effective way to reduce the likelihood of a similar event happening in the future? I have addressed this topic fully below. At heart, the answer goes to the definition of the “just culture” that has been adopted by a hospital.

But let’s talk about the second one: What makes the patient and family feel better in a situation like this?

The literature on the topic of disclosure and apology suggests that patients and families are not interested in having the doctor or nurse be punished when a medical error occurs, if (and this is an important if), the clinician makes clear that he or she is clearly regretful about the error, is empathetic with the patient, and if the clinician and hospital show that they plan to learn from the error to help avoid repeats with other patients.

We can speculate on why this is the case. I heard IHI’s Jim Conway discuss this once, and I think he had it right. Jim said that patients want to trust their doctors and nurses. That trust is enhanced when a clinician makes a clear and honest admission of an error and shows that s/he cares about the additional pain and suffering imposed on the patient.

However, the patient also wants to know that something has been learned from the experience. S/he wants an assurance that his or her pain is not in vain, that other patients will be less likely to suffer similar harm. This tendency comes from the inherent goodness in most people. We do not mind making personal sacrifices if other people are helped and a greater good emerges.

But, an additional step adds even greater value. As noted by Tom Delbanco and Sigall Bell:

Perhaps most important, building bridges to injured patients necessitates including them and other patients in the development of solutions. Patients and families will bring ideas to the table that expand the horizons of health care professionals. The yield from working in partnership could be enormous, both improving people’s experience with medical error and preventing harm from occurring in the future.

* A slight correction for Jessie: The decision about punishing a member of the medical staff for clinical errors generally lies with the Chief of Service and with the hospital’s Medical Executive Committee, not with the CEO. But I certainly concurred in this case.

Paul Levy is the President and CEO of Beth Israel Deconess Medical Center in Boston. Paul recently became the focus of much media attention when he decided to publish infection rates at his hospital, despite the fact that under Massachusetts law he is not yet required to do so. For the past three years he has blogged about his experiences in an online journal, Running a Hospital, one of the few blogs we know of maintained by a senior hospital executive.

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2 replies »

  1. I think there is a danger on placing too much emphasis on the patient’s desire to feel that lessons will be learnt, rather than on actually learning those lessons and altering the systems which allow such mistake to take place.
    Ensuring that those who harm their patients are punished creates a greater incentive for these systematic changes, in addition to holding the individual involved personally accountable. If doctors know that the convenience of their current systems causes some minor additional risk to patients, they are more likely to insist upon a change being made if they know that any harm they do to their patients will have serious personal consequences for them as well.
    It’s to easy to always assume the best of health professionals, and act is if they are now motivated by the same self-interest which seems to corrupt others in positions of authority. Such a belief may be comforting, but I do not think it is true.

  2. As one who has been through many medical procedures with family members who likely would still be here had it not been for the errors of medical staff, this is an interesting debate. I really had not thought about punishing the individual vs. the hospital. In our highly litigious society it is more common (beneficial) to go after the institution rather than the individual.
    I see medicine as a team sport where the actions of one impact the whole, but in the event of failure, the whole carries the burden.
    As I continue to live the Day1 philosophy, I will be sure to give this topic more thought