Hierarchies: the Berlin Wall of patient safety

Reporting and preventing adverse events is the theme in two papers in this issue. In their commentary, Murff and Dittus1 suggest that nurses and pharmacists could report medication errors and equipment failures during clinical research, and Seiden et al2 identify a role for medical students in recognising and preventing errors during their clinical attachments.

While I agree with their recommendations for improved reporting, enhanced communication and acting ethically, I remain sceptical that change will occur without significant examination and understanding of the role of hierarchies in our healthcare system.

UNDERSTANDING WHERE WE HAVE COME FROM

The word “hierarchy”, first found in 1380 in the Oxford English Dictionary, referred to priests in relation to God. Today the term has broader application and refers to a group of individuals ranked according to authority, capacity, or position. At the turn of the 20th century hospitals were organised into hierarchical structures with the medical hierarchy at the pinnacle.3 Typically, this involved ever increasing power with each rank subject to the authority of the next level up. This arrangement has endured despite increased complexity and costs and significant changes in technology. Hospital patient populations, clinical pathways, and workforce have radically changed over the last three decades, yet the organisational structure for doctors remains substantially unchanged since the 19th century.4 New areas (specialties and subspecialties) have been accommodated by adding to existing structures, creating departments and hierarchies often without reference to the needs of patients.

Nineteenth century medical apprentices were legally …