Risk management and patient safety often conflicting goals

Those of us who work in health care live in a culture of blame. The Institute of Medicine's egregious spin of data on patient harm and wrong thinking about never events added fuel to the fire with the result that the patient safety movement backfired.

DB's Medical Rant's offers a case in point:

Talking to a colleague recently, he told me about a teaching case. The patient had almost died and a root cause analysis led to many important teaching points. He wanted to do an M&M presentation, and had to defy the hospital lawyers. The lawyers (at his hospital) told him that he should wait 8 years to use the case in a teaching conference.