A “blame and shame mentality” only hinders investigations into “adverse events” in healthcare, according to Bermuda Hospitals Board chief of staff Michael Weitekamp.

However, Dr Weitekamp added that “shield legislation” offered in Friday’s Throne Speech for physicians and BHB officers engaged in investigations did not offer a blanket immunity from lawsuits.

The Ministry of Health and Seniors will use the upcoming session of Parliament to bring legal protection for BHB staff carrying out quality improvement and peer reviews.

Dr Weitekamp said the circumstances of adverse events or near misses needed to be studied, in what the medical system calls a “root cause analysis”.

“The purpose of a root cause analysis is to better understand what went wrong, so that policies, processes, tools, techniques, workflow, staffing, training or whatever else was discovered to be contributory can be corrected going forward, in order to minimise the chances of such an event taking place in the future,” he said.

“Most adverse events in healthcare — as is true of all highly technical and complicated industries, such as aviation, manufacturing and nuclear power generation — are the result of systems issues, rather than individual negligence.

“However, for a root cause analysis to be successful and comprehensive, a ‘blame and shame’ mentality must be left at the door, and the analysis must focus on facts, not on pointing fingers.”

The BHB staff chief said that “frank conversations and truth finding” had been shown to be inhibited by “fear of retribution in the form of dismissal, litigation or some other form of public shame”.

“Thus, best practice in most jurisdictions in the US at least, is to protect, or ‘shield’ such important process improvement activities from direct discovery, in the event that the adverse outcomes results in litigation and a claim of negligence,” he said.

Healthcare providers can still be sued, and medical records or other evidence can still be used as the basis for litigation, he said.

“It is only the root cause analysis and process improvement work that is ‘shielded’ from discovery,” Dr Weitekamp explained.