The Adverse Event of Unaddressed Medical Error

Abstract

In this article, Professor Liang, using a systems analysis paradigm, reviews failures in medicine and law and concludes there has been a significant adverse policy event: a health delivery system where medical error is broadly unaddressed. After a review of the basic concepts of error incidence and analysis, he discusses system holes and failures represented by medical culture, risk management, and the JCAHO sentinel event policy. He then turns to legal holes, including medical liability, independent contractor law, privilege law, and federal medical privacy provisions. On the basis of these findings, he proposes a federal solution that centers on voluntary reporting of errors with a focus on near misses, an infrastructure that does not involve entities that can sanction, a systems-based medical culture and educational approach, publication of patient safety efforts as a competitive characteristic, replacing the tort system with a mediation-based system that promotes opens communication between providers and patients as well as compensates injured patients rapidly, and Congressional reform of medical privacy provisions to facilitate patient safety work.

Keywords: Medical error, patient safety, legal system

JEL Classification: H4, H51, I0, I18, K0, K13