Moin Rahman wrote a very informative piece about the various factors which influence emergency healthcare.
He clearly illustrates the stages which occurred in the case study of a child who died from septic shock as a result of a small cut he received whilst playing basketball. Fits beautifully into the safety management systemframework.
What is apparent immediately is that it reflects a common theme in society – the tendency to attribute blame to the end user despite the underlying reasons for an incident. As is so often the case in other areas such as aviation, road use and military applications, ‘human error’ is commonly given as the reason an incident occurred, often with deadly consequences. However, as Moin succinctly points out, there are very clear underlying factors that are probably more important and should be highlighted. The root cause is the process which almost makes the final act, in this case the death of a child, almost inevitable.
Unfortunately, as in many fields where there is a high aspect of skill or ‘art’ in a profession such as medicine, these root causes are too often subsumed as there is an easy scapegoat on whom to focus attention. But what about the lack of funding, high workload and lack of resourcing common in the medical field, especially in public-funded or profit-driven private hospitals.
As is now the case in OH&S matters, managers are increasingly being scrutinised regarding their contribution to an incident. Adopting Reason’s (1990) model as described in Moin’s article, their function is to provide the first three layers of the safety system and one would expect that they should shoulder an appropriate proportion of the blame if something does go wrong. Perhaps they would be less inclined to reduce services if they were held truly accountable for their actions. Perhaps the accountants who have no knowledge of the coalface and make cost cutting decisions without first taking a reasonable view of the potential results could take a fair cop as well.
But then, how will they know what is wrong? What is a reasonable view? A theme which I have espoused in my other blogs is that many, if not all systems contain humans as an integral part. Therefore, a scientific, objective assessment of the human in the system should be fundamental. And given human scientist expertise in this area, it should be evident that they would be best placed to undertake this role.