Naming those responsible for Hep C outbreak breeds blame culture

From ‘Revealing staff involved in Hep C outbreak will breed blame culture: Health Minister’, 4 Apr 2016, article in CNA

Revealing the names and specific sanctions received by staff from the Ministry of Health (MOH) and Singapore General Hospital (SGH) in the wake of the Hepatitis C outbreak last year would not “contribute to better care of patients”, said Health Minister Gan Kim Yong in Parliament on Monday (Apr 4).

Mr Gan was responding to a question by Non-Constituency Member of Parliament (NCMP) Leon Perera, which called for the disclosure of the names and punishments of the outbreak at SGH’s renal ward that claimed eight lives.

In total, four MOH officers holding Director-level or equivalent roles and 12 SGH leaders including senior management were punished.

“Instead of focusing on naming the individuals and developing a blame culture in our healthcare institutions, we need to encourage a learning culture to make our hospitals as safe as possible for our patients,” said Mr Gan. “This culture of continual learning and improvement is important for enhancing patient safety and the quality of care.”

In 2014, a hospital pharmacist was name-checked in the media for a fatal medication error (Negligent pharmacist fined for causing patient’s death with overdose, 16 May 2014, ST), and no one of any authority was there to deflect blame and preach about transforming the finger-pointing into a ‘learning culture’. Supporters of the name-and-shame method remember how Roy Ngerng was sacked for ‘misusing TTSH time and resources to pursue personal interests’. More recently, a single doctor was identified and fined after wrongly administering a chemo drug into a patient’s spine instead of a vein. The harsher sentence is that the Internet remembers and is there to constantly remind you of the gravest mistake of your life.

Back in 2009, however, in a medication error involving cancer drugs delivered via infusion pumps in which 2 KKH pharmacists were involved, no names were leaked. The same level of secrecy was evident in the baby mix-up saga from the very same hospital. It does appear that there’s ‘safety in numbers’ looking at the examples above. If more than a dozen senior people from both MOH and SGH were judged to be collectively responsible, the whole chain-gang is protected behind a security blanket. If one pharmacist, nurse or doctor is responsible, he or she is left to fend for their reputation for the rest of their lives. More like a ‘dilution of blame’ culture, it seems. If a man is clutching his chest panting for dear life in the street and you’re the only person around and you do absolutely nothing, you’re a heartless bastard. If you’re among a crowd of useless bystanders, however, the guy on the floor was just unlucky.

Whether or not one chooses to use public shaming to deter others for the greater good, the fact that a terrible mistake has been made means that there should be a ‘learning and improvement process’ in place ANYWAY. Keeping mum about the identities of culprits has nothing to do with subsequent mitigation measures. You could also argue the alternative view, that revealing names and sanctions would actually ‘contribute to better care’ on the contrary, like how capital punishment contributes to a drug-free Singapore.

Advertisements

3 Responses

  1. […] – New Nation: Hep C outbreak: Reserve blame culture for Workers’ Party, opponents of ruling PAP govt – Everything Also Complain: Naming those responsible for Hep C outbreak breeds blame culture […]

  2. […] Naming those responsible for Hep C outbreak breeds blame culture – “Whether or not one chooses to use public shaming to deter others for the greater good, the fact that a terrible mistake has been made means that there should be a ‘learning and improvement process’ in place ANYWAY. Keeping mum about the identities of culprits has nothing to do with subsequent mitigation measures.” […]

  3. […] It does appear that there’s ‘safety in numbers’ looking at the examples above. If more than a dozen senior people from both MOH and SGH were judged to be collectively responsible, the whole chain-gang is protected behind a security blanket. If one pharmacist, nurse or doctor is responsible, he or she is left to fend for their reputation for the rest of their lives. More like a ‘dilution of blame’ culture, it seems. If a man is clutching his chest panting for dear life in the street and you’re the only person around and you do absolutely nothing, you’re a heartless bastard. If you’re among a crowd of useless bystanders, however, the guy on the floor was just unlucky. Whether or not one chooses to use public shaming to deter others for the greater good, the fact that a terrible mistake has been made means that there should be a ‘learning and improvement process’ in place ANYWAY. Keeping mum about the identities of culprits has nothing to do with subsequent mitigation measures. You could also argue the alternative view, that revealing names and sanctions would actually ‘contribute to better care’ on the contrary, like how capital punishment contributes to a drug-free Singapore.  […]

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Google+ photo

You are commenting using your Google+ account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s

%d bloggers like this: