The ACC reforms for treatment injury should replace a culture of blame with a culture of safety.

Listener: 17 April, 2004.

Keywords: Social Policy;

A friend recovering from a serious operation was on two occasions offered medicine that was not prescribed and, once, a scan that was unnecessary. Suppose she had been unconscious, or lacked the character to know what was going on and say “no”. Whether the mistakes could have led to medical injury, I cannot tell. But they would have consumed scarce resources.

This is not to point the finger at the health professionals involved. I find more helpful a diagram in a prize-winning book by Dr Peter Roberts, Snakes and Ladders: The pursuit of a safety culture in New Zealand public hospitals. It shows a stack of punch cards representing the chain of decisions. It is only when there is an alignment of the holes of failure that a “medical incident” occurs. To focus solely on the hole in the last card is to ignore the earlier ones. A safety culture looks at all the holes.

This was part of the reason that the 1966 Woodhouse Commission rejected fault in its accident compensation proposals. Blame is too complicated and erratic. Instead, the ACC system was based on the principles of the priority of prevention with (prompt) rehabilitation and (fair) compensation, where an accident occurred.

Oddly, however, the fault principle still applies in the case of medical misadventure, because the injured may be entitled to compensation if it can be proven there was a medical error. (The other major ground is that if there is a medical mishap with a rare and severe outcome.) The fossil is instructive because it demonstrates that the Woodhouse Commission was right: where there is a fault principle, rehabilitation is delayed and compensation is erratic.

Following a review, the ACC Minister has announced that she will be introducing legislation to put medical misadventure (in future to be known as “treatment injury”) on a new footing. It is intended that “treatment injury” will cover injuries whether they are serious or not, but exclude “injuries that are a necessary part of treatment, such as a surgical incision, and those that result from a patient’s underlying condition. Nor will there be cover just because the desired results were not achieved or the treatment was not 100 per cent successful.”

The scheme is expected to add another $8.7m to the current cost of $47m a year for medical misadventure, while accelerating and simplifying the decision process. I hope so, especially if it speeds up rehabilitation, which must be a greater priority than compensation.

Will the scheme go far enough? Woodhouse emphasised the importance of prevention. Undoubtedly, medical error has discouraged prevention, because the first reaction of a health professional faced with a charge of incompetence is to obfuscate (don’t we all?). Eliminating a culture of blame will discourage such reactions. (Patients can still complain to the Health and Disability Commissioner or the relevant professional body, as can ACC where it considers there is “a risk of harm to the public”.)

But the lesson from the medical incidents with which this column began, is that not all result in treatment injury, so they don’t all reach ACC. Yet they still reflect a safety failure that could happen again unless the system – all the cards – is addressed. Next time the failure could end up at ACC. So, as Peter Roberts argues, we need to build a safety culture into our medical system.

There can be no universal prescription. An intensive care unit will have a different system of incident review from a podiatrist. However, there are a number of agencies with safety responsibilities: the Ministry of Health, the Health and Disability Commissioner, the professional associations and their disciplinary boards, and the treatment institution, as well as ACC. The danger is that no one will take responsibility, and the opportunity for greater prevention will be lost.

So we may applaud the proposed reforms, and celebrate that some patients who would have a rough deal on past criteria will be better off. But the health professionals are also better off for not having a culture of blame hanging over them. In return, they should make a real commitment to instigate a culture of safety in their practice, addressing medical incidents, and not just accidents. The biggest gains from the reform could be for the patients who never get to ACC, because better prevention means they do not suffer treatment injury.