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Kurup’s prescription for reporting medical errors

Staff Reporter

KOCHI: The culture of blame, shame, punishment, and peer condemnation are clear shackles in reporting medical errors, said K. Narayana Kurup, the former Acting Chief Justice of the Madras High Court.

Delivering the inaugural address at a State-level Anaesthesiology Conference held at Kottayam on Saturday, Mr. Kurup said to change this state of affairs, the patient and society should be forgiving, thus making it possible to approach the mistake with a “problem-solving focus.”

“We should create an atmosphere which will be conducive for the doctors to come out of their shells and to resort to error reporting freely by ensuring immunity as far as practicable,” he said.

Until then error reporting would continue to be an “untapped resource” at the risk of the patient community, he said.

Mr. Kurup said often when medical errors occur, the tendency is to throw the blame on “the last person in the chain,” making him the scapegoat. Removing that particular individual without correcting the system simply creates a situation where his or her replacement would be vulnerable to a recurrence of the same problem.

“The correct approach is to ‘re-design systems,’ so that errors are acknowledged, detected, intercepted and investigated,” Mr. Kurup said.

An acceptable safe system should have inbuilt procedures to make errors visible to those working in the system so that they could be corrected before actual harm was caused, he said.

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