Medical Error and Patient Safety: Understanding Cultures in Conflict

Evidence documenting the high rate of medical errors to patients has taken a prominent place on the health care radar screen. The injuries and deaths associated with medical errors represent a major public health problem with significant economic costs and erosion of trust in the health care system. Between 44,000 and 98,000 deaths due to preventable medical errors are estimated to occur each year, making medical errors the eighth leading cause of death in the United States. However, the recent prominence of the issue of safety or error does not reflect a new phenomenon or sudden rift in the quality of health care (although it is a system fraying at the edges). Rather, the prominence of the issue reflects a radical change in the culture of health care, and in how relationships within the health care system are structured and perceived. In this paper, I discuss the multiple factors responsible for the change in the culture of health care. First, the culture has shifted from a clinician cantered system, in which decision making is one–sided, to a shared system of negotiated care between clinician and patient, and, often, between administrator or payer. Second, the nature of quality in health care has changed due to the geometric increase in the availability of technological and pharmaceutical enhancements to patient care. Third, the health care culture continues to rely on outdated models of conflict resolution. Finally, the regulatory structure of health system oversight was set in place when fee–for–service care governed physician–patient relationships and where few external technologies were available. In the current health care culture, that structure seems inadequate and diffuse, with multiple and overlapping federal and state regulatory structures that make implementation of patient safety systems difficult.     

The Policymaking Role of State Supreme Courts in Education Policy

In this article, I examine the relationship between courts and legislatures from a comparative perspective. Specifically, I discuss how (1) the ideological composition of the bench, (2) the propensity of court involvement in a given policy area, and (3) the presence of an advisory opinion affect the number of bill introductions and policy enactments by state legislatures. Examination of education policy in the American states reveals that ideologically distant courts limit the number of bill introductions and bill enactments in state legislatures. Alternatively, the presence of an advisory opinion increases policy introduction and enactment in state legislatures. A fundamental implication of these findings is that courts exert the greatest impact on policy during the introduction stage of the legislative process. Previous studies have not examined the introduction stage and have therefore marginalized the real impact of court influence on policy.     

Legislative Demands for Bureaucratic Policymaking: The Case of State Medical Boards

Abstract While much is known about the relationship between Congress and regulatory agencies, there has been little examination of the role state legislatures play in the activities of state regulatory bodies, particularly those activities related to timely, salient policy issues. This article explores the relationship of state legislatures to medical boards, which are increasingly becoming more policy active. We find that state legislative involvement and influence are the most important determinants of policy‐active state medical boards; institutional elements play a secondary role. Major changes in the private health care delivery system affect legislative involvement and play an indirect role in predicting policy activism. We drew our data from a 50‐state survey of executive directors of state medical boards.     

Safety,Regulation and Tort: Fault in Context

The relationship between tort and regulation is dense and complicated. This paper examines diverse approaches to one small element of this relationship: the relationship between regulatory norms and the standard of care in personal injury cases. The lack of clear rules governing that interaction is not surprising: we would never expect the courts to give up the authority (or abdicate the responsibility) to generate private law norms; on the other hand, nor would we expect them to ignore the potential authority and legitimacy of external norms. The strength of external standards is best identified by close scrutiny of the regulation itself. The varying authority of external norms in a private law forum requires engagement with the process by which the external norms were reached. Who and what determined the ‘ought’ of regulation will provide greater insight into the ways in which it should inform the ‘ought’ of tort.     

Globalizing Regulation: Reaching Beyond the Borders of Chemical Safety

This article argues that although globalization can benefit both exporters and importers of regulation in absolute terms, it may turn the globalization of regulation into a game with relative winners and losers. Using the EU REACH Regulation of chemicals as a case study, it explores the normative, social, economic, and strategic reasons that push the EU to promote the global adoption of REACH. Notwithstanding its attractions, rules globalization may result in a mismatch between global norms and local priorities, particularly for developing countries. It reduces regulatory diversity, and amplifies the strengths but equally the weaknesses of the dominant regulatory framework. While it can foster international trade through mutual recognition of regulatory decisions and the development of transnational regulatory frameworks, it increases the likelihood of conflict and trade flow desequilibria. The article calls for further careful consideration of rules globalization, so that harmonization does not come at the expense of local interests and values.     

The Role,Benefits, and Concerns of Digital Technology in the Family Justice System

Digitalization is increasing across family justice systems around the world. What are the benefits? What will be the impact on professional practice and legal representation? What are the concerns for those who may be digitally disadvantaged? How much can justice itself become digital?     

Regulation and the Role of Trust: Reflections from the Mining Industry

The role of prosecution in achieving compliance with social regulation is a highly contentious issue, nowhere more so than with regard to work-related injury and death in the New South Wales mining industry. Following a mining disaster, political pressure prompted the mines inspectorate to abandon its traditional 'advise and persuade' approach in favour of a much tougher, deterrence-oriented approach. Our field-work suggests that while the former approach can result in regulatory capture, the latter can be equally counterproductive. In the mining industry, interactions between inspectors and the regulated industry are frequent and ongoing and trust is central to constructive relations. When those relations break down (as under an inappropriate prosecution policy) then dialogue ceases, information is withheld rather than shared, in-firm accident investigation, prevention, and remedial action are inhibited and both sides retreat to a form of adversarialism that undermines regulatory effectiveness. Through a 20-year case study of the mines inspectorate, the article demonstrates the centrality of trust to regulatory effectiveness, how it can be lost, and how it can best be regained.     

Moving Beyond Command-and-Control: Reflexivity in the Regulation of Occupational Safety and Health and the Environment

Direct or "command-and-control" regulation has had limited success in dealing with occupational health and safety and with environmental regulation. This lack of success has led policymakers to experiment with self-regulation as an alternative means of achieving the goals of social regulation. The economic subsystem fails to acknowledge its social identity and, therefore, appears to be blind to its negative performance regarding the environment and the workplace. The authors of this paper argue that moving beyond command-and-control can be feasible and desirable, at least to a certain extent, but that pitfalls are omnipresent. "Regulatory dilemmas" need to be solved, sound empirical studies need to be conducted, and a guiding theory needs to be drafted. To achieve these goals, the authors suggest use of the key concept of "reflexivity," which refers to the economic organization's relationship with itself. The practical usefulness of this theoretical concept is explored against the background of regulatory practice in the areas of occupational safety and health and the environment. It is concluded that a mode of reflexive administrative law requires a "negotiating government," which adopts a mixture of strategies and learns to cope with issues like third-party interests, access to information, and enforcement.     

Safety in Intimate Partnerships: The Role of Appraisals and Threat

For most intimate partners, safety is an important goal and basic need. How a partner perceives safety has an impact on what happens in the relationship, and this will in turn affect the responses from the other partner. Lack of safety can provoke negative emotions and actions which can lead to relationship deterioration and violence. However, little is known about this process from the insider’s perspective. In this study, constructivist grounded theory methods were used to analyze interviews from individuals (n = 37) to better understand individual appraisals of relational safety. The results include a theory that illustrates the process of relational safety and threat. This model articulates how certain relational conditions precede a perception of safety or threat, which then leads to corresponding actions. Implications of the model include a focus on interaction and context when assessing for safety and abuse, as well as the importance of self regulation.     

Global and Domestic Governance: Modes of Interdependence in Regulatory Policymaking

Abstract:  This article examines how the regulatory policies of countries are interdependent. In particular, it identifies three modes of interdependence: competitive, coordinative, and informational. In the competitive mode the essential structure of interdependence is for countries to attempt to have distinctive policies that provide some advantage over other countries, but where the equilibrium set of policies is suboptimal for all. In the coordinative mode, there is an advantage for all countries to adopt the same policy, but exactly which policy is adopted may have significant distributional consequences. Lastly, in the informational mode, the choices and experiences of countries produce informational externalities, pointing the way for other countries to policy decisions. This article examines the logic underpinning each of these modes of interdependence, and draws out the governance implications of each mode.     

法医在医疗事故技术鉴定活动中的角色定位

法医在医疗事故技术鉴定活动中应扮演什么角色,如何定位,应该起什么作用?<医疗事故处理条例>及相关配套文件并未做明确规定.鉴于此,笔者针对这种情况谈一点新<条例>正式实施一年半来参加鉴定会的粗疏体会,并提出三点不太成熟的建议与同道商榷.     

论最高法院在宏观调控中的角色定位

最高法院对宏观调控的介入具有一定的可能性,但必须充分认识到其介入宏观调控所面临的制度障碍、知识障碍、工具障碍、观念障碍以及成本障碍。最高法院对宏观调控的介入只能是一种被动的消极角色,而且尚必须注重与其他社会系统充分的信息交流和对话,强调司法权的自我约束。     

从规制合规迈向合作规制:以食品安全规制为例

食品安全法制体系的建立健全使得食品安全法治的重点转向法律实施,如守法和执法。其中,食品安全法律要求的不断趋严,使得食品生产经营者日益重视有助于履行法定义务要求的规制合规,并出现了服从性合规、竞争性合规、外生性合规、内生性合规、象征性合规和创造性合规等不同选择。鉴于此,规制者以合规导向的执法替代威慑导向的执法,并由此促进了合作规制的发展。然而,如何回应不同的合规选择和促进规制者和被规制者之间的合作,依旧有赖于规制者构建风险交流、责任约谈、精准普法等促进彼此交流法律认知和分享信息的支持性制度和改进许可、标准等工具适用中的单向且刚性要求。     

Business Responses to the Regulation of Health and Safety in England*

The material in this article is extracted from an empirical study of industrial and agricultural businesses' responses to regulation of health and safety in the workplace. The study critically assesses the philosophy of self-regulation which underpins the regulatory framework in England and within the context of the expectations of employers built into that philosophy, attempts to distinguish between different models of employers in relation to their levels of motivation toward health and safety issues; their knowledge and comprehension of the law; their general approach to compliance with regulations; and their response to inspectors' enforcement activities. The article concludes that self-regulation is only capable of operating under very narrow conditions. It is at its most successful within the largest and most hazardous companies, despite the fact that the inspectorates devote the greatest concentration of enforcement and advisory resources to these sites. Companies which do not have a natural interest in safety require considerable advice, encouragement and coercion. In some situations deterrent penalties may be required in order to achieve a sustained improvement in standards. The research suggests that greater attention should be paid to the variety of employers and their compliance strategies, and to the potential for better targeting of regulatory efforts.