It should be mandatory for medical experts’ reports to consider the role systems issues have played in an adverse patient outcome, according to a defence body.
Medical expert reports focus on scrutinising an individual doctor’s action – risking them being scapegoats for failings of the settings where they work, it says.
A report from the Medical Protection Society (MPS) entitled Getting it right when things go wrong: the role of the medical expert insists that organisational or systems failures which may have played a part in an incident must be included as standard in expert reports.
Medical director Dr Rob Hendry said experts had to address individual performance concerns, but ‘all too often’ doctors were blamed for workplace failings.
‘Patients and families also deserve a thorough explanation of what has happened and reassurance that the same thing will not happen again, and taking a broad focus and identifying all factors contributing to an adverse incident is vital in achieving this.
‘This, however, does not always happen and many expert reports focus solely on the actions of the individual without considering the wider context.
‘In reality, patient harm arising from medical error is rarely attributable to the actions of a single individual.
‘Inadequate staffing levels, lack of resources or faulty IT systems are just some issues which can contribute to adverse incidents. Doctors confront these issues every day and have little influence over them.’
The MPS report also sets out steps aimed at widening the pool of appropriately qualified medical experts.