The Pediatric Cardiac Surgery Inquest Report



Dealing with human error

Error can be handled in two very different ways. One way is to seek out and identify the one who committed the error in order to hold him or her, or the institution that employs the 'culprit', responsible for it. The other way is analyse the error in order to learn from it and to improve things so as to reduce the probability that the error will not be made again.



Blaming or holding people responsible and accountable for their actions, such as those types of error which involve violations of existing standards or rules, is a major focus of the court system. The laws of torts, of contracts, child welfare and crime-among others-all focus on the consequences that come to bear, or at least ought to, on the person who commits a legal wrong.

Legal blaming involves a determination of culpability in order for the system to become engaged in the resolution of the matter. Legal blaming, or fault finding, is a normal (indeed, perhaps even necessary) aspect of resolving and addressing those errors that violate rules or standards. Judicial systems exist in part to provide a vehicle by which individuals can address the question of wrongs that are committed against them or their loved ones, in order that they can relieve their feelings of loss, pain and anger. Without a properly functioning judicial system, some have argued that people may surrender to the urge to exact revenge for their loss and pain upon the individual or institution they feel is most responsible.


Learning from human error

However, because inquests are not able to make findings of culpability, the obligation of an inquest ought therefore to be to focus on discussing error in the context of what can be learned from it.

For the same reason, hospitals need to approach the issue of error from a learning perspective, for they have an obligation to provide the best possible care to their patients. If it is discovered that a problem has resulted from human error during the course of treatment, then hospitals ought to be empowered-indeed obligated-to consider such error from the perspective of what can be learned. In particular, efforts should be made to determine how to prevent errors from recurring, by discovering where the flaws lie in the system that contributed to errors being made.

In order to do so, a process must be put into place that emphasizes the need to gather and consider all of the relevant facts in an honest and candid manner, without regard to any individual or institutional consequences that might flow from the errors.

For that to happen, consideration must obviously be given to balancing the issue of confidentiality and protection of informants from liability for describing what happened, with the equally strong need for patients and their families to be informed as to what really happened.



Current Home - Table of Contents - Chapter 10 - Dealing with human error
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Previous Error, accident and humanity
Section 1 Chapter 1 - Introduction to the Issues
  Chapter 2 - Pediatric Cardiac Issues
  Chapter 3 - The Diagnosis of Pediatric Heart Defects and their Surgical Treatment
  Chapter 4 - The Health Sciences Centre
Section 2 Chapter 5 - Pediatric Cardiac Surgery in Winnipeg 1950-1993
  Chapter 6 - The Restart of Pediatric Cardiac Surgery in 1994
January 1, 1994 to May 17, 1994
  Chapter 7 - The Slowdown
May 17 to September 1994
  Chapter 8 - Events Leading to the Suspension of the Program
September 7, 1994 to December 23, 1994
  Chapter 9 - 1995 - The Aftermath of the Shutdown
January to March, 1995
Section 3 Chapter 10 - Findings and Recommendations
Appendix 1 - Glossary of terms used in this report
Appendix 2 - Parties to the Proceedings and counsel
Appendix 3 - List of witnesses and dates of testimony
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