The bad apples versus bad systems argument has erupted again. This argument has been put forcibly in the Los Angeles Times by Philip Levitt. He points out that:
- Error rates are not declining, despite humongous effort. This is not quite right; they declined quite markedly in England over the last decade, and on many dimensions of safety adherence it was near 100%. Nevertheless, adverse events remain a substantial problem.
- Many interventions, such as surgical check-lists  and antisepsis bundles, yield positive interventions when first introduced, but these cannot be replicated.  
- Analysis of the cognitive form of errors put them down mostly to individual failure rather than the system – most are technical errors during procedures, or misdiagnosis. 
- Many studies show that a small pool of doctors generate a large proportion of complaints (3% of doctors triggering half of all complaints in an Australian study). Arguably this proportion would be reflected among adverse events as well.
So maybe we should re-think our basic safety science premises. Certainly, falls, pressure ulcers, hospital infections, and medication errors can be blamed in large part on the system. However, these are not the major safety issues; over three-quarters of serious adverse events result from misdiagnosis and errors during procedures. While the system may play a part in these failures the CLAHRC WM Director, who practised at various times as physician and surgeon, is not convinced that the main problem lies in the system. No, diagnosis and safe surgery turn on individual skill. So we need to think about selection and improving the performance of individual clinicians – most especially those who make diagnoses and carry out procedures (i.e. doctors). Of course, if the definition of the system is made very broad, then of course selection and training are included, but the solution lies in medical schools and training programmes, rather than individual organisations. Can we identify an error prone phenotype before they end up in court or a complaints tribunal? Identifying such a phenotype is elusive – as work carried out in our pilot CLAHRC discovered.
— Richard Lilford, CLAHRC WM Director
- Levitt P. When medical errors kill. Los Angeles Times. 15 March 2014.
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