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President, Canadian Medical Protective Association, Ottawa, Ont.
In a series of recent articles about no-fault compensation, CMAJ raised important questions regarding the Canadian medical liability system.1–3 However, the length of these articles did not permit a full discussion of the issues, which are complex. In consequence, readers may have drawn incorrect conclusions concerning the merits and shortfalls of a no-fault compensation system and its relation with patient safety.
In Canada there are 3 system-level responses to an adverse event, each of which has its own role and defined processes. (An adverse event is defined as an event that results in unintended harm to the patient and is related to the care or services provided to the patient rather than to the patient's underlying medical condition.4) The effectiveness of the system depends, in part, on the balanced application of these responses. The patient-safety response involves learning from the event to prevent a similar result in the future, if this is possible. The professional-accountability response ensures that physicians and other health professionals meet the established standards of care. It is a vital element in ensuring public confidence in the health care system. The third response is the provision of compensation to patients injured as a result of negligent medical care; in Canada, this is generally achieved through the tort-based litigation system.
In part 2 of her series on no-fault compensation, Ann Silversides implies that removal of the fear of litigation would improve the safety of medicine through more open reporting and enhanced learning.2 This reflects the common misunderstanding that "no fault" equals "no blame" and therefore involves less stress for patients and providers. However, the so-called no-fault medical liability systems studied by the Canadian Medical Protective Association all include a significant aspect of fault determination, most often through professional accountability frameworks.5 In Canada, this professional accountability is the responsibility of the regulatory authorities. However, in many no-fault jurisdictions, fault finding occurs without the procedural process and fairness that characterize the current Canadian model.
There is no evidence to support the assertion that no-fault systems are more supportive of patient safety and the determination of the reasons for adverse events than other liability systems. The Canadian Medical Protective Association believes that the development of a just culture of safety in health care that supports full reporting and discussion of adverse events is an important contributor to patient safety. Health professionals should be encouraged to actively examine what occurred and to speculate on how an unexpected clinical outcome or adverse event might have been avoided in a nonthreatening learning environment. However, such discussions should be separate from professional accountability and compensation mechanisms and the information provided should be protected from use within those other domains.
All available evidence suggests the focus should be on preventing adverse events by enhancing patient safety. It is these efforts and not the type of liability system that make a difference. The Canadian Medical Protective Association believes those interested in advancing patient safety would have a greater impact if they worked to improve adverse-event quality review processes rather than diverting attention by advocating for no-fault compensation.
Much more can and should be done to improve patient safety, starting with ensuring that quality-improvement processes are in place and adhered to in all jurisdictions. The Canadian Medical Protective Association hopes that discussion of these important issues rather than of no-fault compensation will occupy the attention of physicians and other care providers.
Footnotes
Competing interests: None declared.
REFERENCES
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Copyright 1995-2008, Canadian Medical Association. All rights reserved. ISSN 1488-2329
(e) 0820-3946 (p)
All editorial matter in CMAJ represents the opinions of the authors and not necessarily those of the Canadian Medical Association. |
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