We live in a deterministic universe: at least that is the view of the majority of philosophers and scientists. Determinism is the most intuitive interpretation of our “world” – every event is caused (or determined) by the preceding events, and the prevailing conditions. Determinism therefore challenges the idea of free will: if everything is determined by prior causes and conditions, then where is our agency, our ability to make choices? This is rigorously debated in the philosophical literature, and, broadly speaking, philosophers divide themselves into two camps: the hard determinists (who state that free will is simply an illusion), and the compatabilists (who state that determinism and free will are compatible with each other). (There are other camps too, but the majority of philosophers are in the first two).
Whether or not free will is an illusion, there seems to be very broad agreement that there is a cause for every phenomenon. This is also consistent with our approach to explaining prior events, and with our attempts to learn from the past. When investigating adverse events, we use various tools (e.g. root cause analysis) and data to attempt to identify the causes and conditions which led to a specific occurrence (usually a failure of some sort). However, in complex systems like healthcare, the causes and conditions don’t readily identify themselves, so our best attempts to learn from the past are always severely limited.
If the above is true, then there are several implications for patient safety investigations:
1. Investigators should continuously come back to “what are the prior causes and prevailing conditions” which led to this event? This helps move the focus from the human to the wider system. Prior causes and prevailing conditions may include training / knowledge, in which case training may be required, but there will always be many other factors which lie outside the human scope.
2. Healthcare is so complex that we should never expect to be able to identify the myriad of causes and conditions which are present at the time of an event taking place – it is simply impossible to have knowledge of all of those factors. This is especially limited when using retrospective analysis.
3. If we were to “rewind the clock” and replay any given situation we can be 100% sure that precisely the same events would happen again. This is true because the same causes and conditions would be present, so it would be impossible for any other outcome to occur. We would make the same choices, because our choices depend on the prior causes and prevailing conditions.
4. We should be honest with patients and families (and staff) by explaining that attempts to understand the past will be limited.
5. There is no place for blame. Our ‘choices’ are dependent on prior causes and prevailing conditions. We would make exactly the same ‘choices’ if we were in the same situation, with the same conditions. Blame is illogical except in the very rare situation where the deliberate ‘choice’ was made to cause harm.
6. It is important to apologise for harm, even in the absence of blame. The system is imperfect and it is our duty to improve it to the best of our ability.