Reference no: EM133517837
Case Study: In 1999, the Institute of Medicine (IOM) published the groundbreaking report To Err Is Hu- man: Building a Safer Health System. It reported that "at least 44,000 people, and perhaps as many as 98,000 people, die in hospitals each year as a result of medical errors that could have been prevented" (Kohn, Corrigan, and Donaldson 1999). In fact, more people died from preventable medical errors in hospitals than from motor vehicle accidents and breast cancer combined. In response to the report,
The Joint Commission issued a cluster of standards in support of patient safety (effective in 2001). One standard specifically required that all unanticipated outcomes of care be disclosed to patients (Henry 2005); see the "Disclosing Medical Errors" section in Chapter 4.
Congress enacted the Patient Safety and Quality Improvement Act of 2005. The goal of the act is to improve patient safety by encouraging voluntary and confidential re- porting of medical errors and other adverse events. Healthcare providers report data about adverse events to patient safety organizations, which, in turn, collect, aggregate, and analyze the data. The act provides federal legal privilege and confidentiality protections for conducting patient safety activities. Regulations implementing the act were effective in 2009 (HHS 2014).
Over the past 15 years, only some small improvements have been made in the US healthcare system's safety and quality, despite accreditation standards; federal law; and healthcare organizations' investment of considerable time, energy, and resources into the effort. However, the improvements are not widespread and are insufficient given the magnitude of the problem (Chassin 2013)
Questions
- Why do healthcare organizations have an ethical obligation to provide a safe environment?
- How do ethical principles support The Joint Commission's standard requiring that all unanticipated outcomes of care be disclosed to patients?
- A nonmoral concern is the cooperation clause in policies for malpractice and professional liability insurance. An admission of error (fault) can void the coverage for related claims (Banja 2004). How does this nonmoral concern affect the disclosure of unanticipated outcomes?
- What ethical obligations do healthcare managers have to contribute to the safety of their organization's environment?
- Which standards of professional codes of ethics relate to establishing and maintaining patient safety?