Healthcare professionals who disclose risks to patients and healthcare organizations are often labelled whistle-blowers. In the United States, "credible reports are that 85% of whistle-blowers will suffer serious repercussions. In Canada, it's probably higher closer to 95%" (Quinn 2006). The result is that patients and communities often end up losing their most passionate advocates, and healthcare loses valuable ethical and moral leadership.

This is not a new phenomenon. Semelweiss in 1850 faced severe opposition and criticism when he discovered that physician practices led to infections in childbirth. Dr. Nancy Oliveri of Toronto faced opposition, criticism and sanctions for disclosing concerns about the safety of a drug undergoing clinical trials. David Graham of the US Food and Drug Administration raised concerns about the safety of Vioxx (rofecoxib) and other drugs, and faced career sanctions. In Ottawa, Drs. Chopra and Haydon were sanctioned for their comments on mad cow disease (bovine spongiform encephalopathy). Most recently, it was felt to be necessary for the Campbell Commission on severe acute respiratory syndrome (SARS) in Ontario to grant "whistle-blower protection" and a promise of anonymity to encourage healthcare workers to give testimony in the investigation about the SARS outbreak in Toronto.

Dangerous practices, ineffective policies and marginal procedures in healthcare may lead to poor patient outcomes. As seen with SARS, contagious disease can spread rapidly from hospitals and immobilize entire healthcare systems and economies. Safety in the healthcare institution requires monitoring of the workplace as well as the continuous improvement of medical procedures and practices. With the reports of hospital-transmitted disease, such as SARS, and antibiotic-resistant bacteria being propagated into the general communities, hospital safety is becoming a public health issue.  

Individual mistakes will occur in our complex health systems. A system responsive to feedback may correct mistakes before lasting damage occurs. In my experience, poor patient outcomes often are a consequence of a series of errors. Errors could become compounded if they are left to propagate through the system. Adverse individual patient outcomes may be viewed as indicators that policies and procedures or practices need to be reviewed and corrected.

Good communication, empowerment of front-line health professionals and continuous education are important elements of self-monitoring and self-correcting healthcare processes. They could lead to high-functioning learning organizations that operate in a state of continuous vigilance, looking for opportunities to improve.

There are risks when the clinical leaders and front-line workers who are proactive about risk management are called whistle-blowers. They are labelled as poor team players and are often isolated and subjected to harassment, threats and even career termination. A second outcome is that co-workers learn that the safest career path is silence and conformity. The third effect could be that a cascade of errors and breakdowns propagate until the consequences become too large to be contained within any single institution and spill out into the general community.  

When an organization is faced with unusual or unexpected threats, conformity dictated by fear may lead to front-line workers being slow to pass information on to the managers. This could lead to either decision paralysis or poor decisions by management. It is in a crisis situation that a culture of empowerment of front-line staff is particularly important. Such empowerment could result in effective and timely organizational decision-making and when it is needed most.

Legislation focused on protecting whistle-blowers may prove ineffective if organizations still find ways to silence internal criticism. Whistle-blower legislation is often enforced retroactive to the event. It does not directly put the onus on management to create open and responsive policies that proactively establish best practices at all times. Such legislation does not protect the health professional who may recognize risks far ahead of the possible consequences. Processes need to be in place to independently investigate and act on concerns that are raised by staff who have the best intentions to safeguard our patients and communities.

Legislation should place organizational accountability at the board level for creating and monitoring a culture of empowerment for front-line workers and clinical leaders. Health professionals need to follow established internal procedures for identifying and reporting unsafe behaviours and practices. These procedures should ensure that concerns are dealt with transparently, without negative consequences to the individual who is acting in the best interests of patients and the public. The boards of our hospitals, along with senior management, need to be held accountable for establishing an open, honest and ethical environment.  

Errors and adverse patient outcomes are opportunities for learning and continuous improvement for the entire healthcare team. Doctors, nurses and technologists must be encouraged to admit mistakes and monitor themselves, their peers and management. Part of the commitment to protect patients and the public should include the identification of risk, as well as the encouragement to voice concerns about the safety and relevance of our practices, policies and procedures in the workplace.  

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