documented and discussed, with aware- ness, but, it seemed, almost with too much regard for being objective. Hope came from the fact that the conference scope and attendees were dedicated to increasing both awareness of cause and prevention of these daily mistakes. IT’S THE SYSTEM AND THERE IS NO BLAME The presentations and discussions at the conference repeatedly characterized the ex- istence of injury and death from treatment as a system failure. This included the con- cept that there should be no blame attached to the individual(s) involved in the cause of the adverse event. (This would be under- standable if the subject of adverse events were solely in the domain of those respon- sible.) Perhaps the real issue is not blame but discipline findings. But, this shows little respect for the patients who are injured or the family of those who passed away as a result of preventable mistakes. Perhaps the dialogue should focus on when, and what sort of, discipline is appropriate. Without acknowledging the need to employ disci- pline when it is called for, there is the prob- ability of diminished responsibility and less chance for early meaningful change that may save lives and reduce injury. We should remember health care is for the public, and promoting the absence of blame for such a major problem is not necessarily reassuring to the public. CHIROPRACTIC IN SAFETY AND OUTCOMES It is important to state that the subject of informed consent also was mentioned by speakers. Informed consent was a signifi- gant lead-in to the reminder that patient safety should not avoid, but include, the public in the awareness and actions that may put an end to preventable injury and death within the health-care system. As I’ve stated, although the approxi- mately 400 attendees and speaker pre- sentations represented government and professions that were primarily focused on patients in hospital-based care, this did not exclude the concern and aware- ness of the need for safety, outcomes and informed consent in the private practice/ primary-care environment. It is in this area that chiropractic has an immediate opportunity to participate in all patient safety organizations regardless of coun- try, patient or health authority. The frank awareness and magnitude of injury and death gave me a moment of pause to reflect on the years of informa- tion and participation, in many initiatives, of the chiropractic profession. Chiroprac- tic education, practice and research does focus on patient outcomes, and safety. It does so as a normal, responsible function of a profession and its individual doctors. It has also done so as a response to historic and contemporary detractors – in short, chiropractic is no stranger to the issues of patient safety and consent. Upon considering the diversity and sheer frankness of information offered at the conference, including the Canadian Medical Protective Association manuals openly advising its medical members on how to address an adverse event with a patient, some observations can be drawn: • Patient safety is primarily a pro- vincial government and advocacy dmworks.ca can give you a new angle on your marketing. From brochures and flyers to targeted email programs, we have the tools to make your marketing stand out. Do more with dmworks. dmworks.ca/chiro ProFit ©2010 Pitney Bowes Canada Ltd. Powered by: Patients
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