Ethical foundations for a culture of safety

Book Cover: Ethical foundations for a culture of safety
Parte di Bioetica sistematica series:

Sandro Spinsanti


in Accademia Nazionale delle Scienze detta dei Quaranta, Academia Scientiarum et Artium Europaea, Joint Autumnal Conference on: Large constructions versus safety

Rome, Thursday 30 October 2003

pp. 295-296


Simple acts such as getting on a plane, crossing a bridge or entering a hospital involve risk. These and other daily activities, beneficial for the quality of our life, could as well cause serious injury or even death. Technology cannot renounce to human intervention ― at least during project and execution phases in engineering constructions ― and therefore implies the possibility of error.

Errare humanum est: this proverb has appeased aggression from the victims of error, enforcing a sort of fatalistic behavior. A culture of risk control is antithetical to this attitude. Safety is firstly linked to a cultural transformation ― control vs. fatality ― than to technological improvement. The second element of this change is ethical. A culture of safety implies indeed orientation towards criticism rather than submission to authority, transparency rather than blind reliance, pragmatism rather than inclination to procedures or formal legal questions (who is responsible?).

Can this culture be imposed? The answer might be rhetorical: if a culture of safety is accepted in the most vulnerable sectors ― that of medicine ― there is hope that behavior may be changed also in other risk situations. This is exactly what is occurring: error control and prevention is becoming part of the agenda of contemporary medicine. This is the signal of hope that we want to receive.

The starting-point is unfavorable to our goal. Traditionally, an attitude of indulgence has prevailed, or even of impunity, with regards to the error made by heath care professionals. Bernardino Ramazzini, renowned author of the first book on work hygiene (De morbis artificum diatriba, 1700), in the chapter on illnesses of gravediggers points out that medicine owes a lot to them since «they bury the dead together with doctors’ errors». From a legal point of view, the attitude is that a doctor cannot be judged by the same standards as an ordinary person, considering the generai criteria of professional responsibility and taking into account his particular


social position. The law has adopted very wide criteria for professional error and considered excusable, unless professional shows very clear signs of ignorance. We can say that this attitude lasted, at least in Italy, until the end of the 1980s.

The change in social relations, that have concerned medicine as well as other activities based on professional authority and complementary interactions ― where decisions made by professionals and adopted without discussion ― has produced important legal disputes. Errors made by health care professionals (or considered such) are brought in court for criminal charges or compensation for damages. According to the data processing center of the Italian Supreme Court, in Italy sentences against doctors were 0,6% in 1950-1990 and 3,9% in 1991-2000. This judicial situation has not favored the growth of a culture of safety but has rather increased defensive medicine. Even «informed consent», a vital moment in a professional practice that aims at transparency and is oriented towards the participation of the patient in choices, has been used as a self-defense tool by the medical staff.

A completely different strategy is that found in initiatives such as those promoted by the USA Institute of Medicine in the «Chart of safety in medical and assistance practices» proposed by Cittadinanzattiva in Italy. The first started from a detailed analysis of errors occurring in medical practice (Report To err is human. Building a safer health system, 1999). The scope was to introduce in the medical practices ― where, according to the Institute of Medicine, every year in the USA 44.000 to 98.000 people die as a consequence of medical error ― the same error control management adopted in other areas with high risk of human error. For example, in aviation. The notion being that a person who enters a hospital deserves the same level of safety as one who gets on a plane.

The changes to be introduced, so that a culture of safety prevails, are many. The first is awareness of the risk. This aspect is particularly difficult in medicine because people are not used to believing that hospitals are unsafe places and that medicine may not only cure but also induce pathologies (Ivan Illich has called this aspect of medicine «clinical iatrogenesis»). However, not even medicine can avoid this process involving empowerment of people, which implies the right to know the benefits, risks, collateral effects, and possible complications linked to the interventions proposed to them by health care professionals.

A culture of safety requires a different approach by health care professionals regarding errors, clinical accidents or all those events that very often end with tragic results. There are better things that can be done with errors then hiding them. It is possible to use them in order to avoid further adverse situations. Errors can be helpful for the improvement of medical practices and, therefore, safety.