Page Section: Centre Content Column

The Joanna Briggs Institute for evidence based nursing and midwifery

3rd Austrasian colloquim
4 March 2002, Auckland

Ron Paterson
Health and Disability Commissioner

Complaints and patients' rights - improving the quality of nursing care

Background

Thirteen years ago, the watershed 1988 Report of the Cervical Cancer Inquiry^[1] shook the New Zealand medical establishment to its roots, and signalled a fundamental shift in public attitudes. Demands for patient autonomy challenged the traditional approach of beneficence and paternalism, and led to reforms of the medical disciplinary process. An independent statutory Ombudsman - the Health and Disability Commissioner - was created in 1994 to develop and enforce a Code of Consumers' Rights designed to "promote and protect the rights of health consumers" and "facilitate the fair, simple, speedy, and efficient resolution of complaints". ^[2]

What rights are covered?

The Code^[3] provides no right to access health care (although it will enforce a duty to provide emergency care, where that is ethically required), but does regulate the quality of care. Services must be provided with reasonable skill and care, in compliance with legal, professional, ethical, and other relevant standards, and by providers who co-operate to ensure quality and continuity of care.^[4] Any person may complain to the Commissioner, or local advocacy services, alleging a breach of a consumer's rights. Consumers are widely defined, to cover all users of health or disability services (not simply patients in traditional hospital and community settings), and a broad range of providers (from institutional providers, and registered health professionals to alternative providers) are subject to the Code. The focus of investigations and reports is on resolution of complaints at the lowest appropriate level, rehabilitation (usually by self- or peer review) of practitioners whose care is found deficient, and public education.^[5] There has been a dramatic decline in the number of medical practitioners facing disciplinary charges since the establishment of the Commissioner's Office.^[6] The introduction of the Code does not appear to have had an impact on the number of disciplinary hearings for nurses which has remained relatively constant over the last six years. ^[7]

Health professional regulation

The Health Commissioner legislation is complemented by health professional enactments, such as the Nurses Act 1977. This Act gives statutory authority to the Nursing Council of New Zealand to set and monitor standards of nursing and midwifery practice in New Zealand.^[8] For some years now nurses have been lobbying for new legislation to replace the Act and midwives want separate legislation to regulate their practice.^[9] If the Health Practitioners Competency Assurance (HPCA) Bill is passed both of these wishes may be granted. Under the new proposed statutory framework a single Act will cover the 11 groups of health professionals currently regulated under individual statutes. The new scheme separates discipline and registration functions with one disciplinary tribunal for all professionals registered under the one statute. The composition of the Tribunal for each hearing will include members of the same professional group as the person charged. ^[10]

The HPCA Bill places an emphasis on competency review and public safety, similar to that seen in the Medical Practitioners Act 1995 (the MPA). The MPA seeks to "protect the health and safety of members of the public" by providing mechanisms to "ensure that medical practitioners are competent to practise medicine".^[11] It has provisions for legally protected quality assurance activities, competence reviews, and recertification programmes, and for supervision of medical professionals, reflecting an enlightened attempt to move away from a simplistic model of medical discipline that seeks to cull "bad apples". As noted in a recent judgment, this rehabilitative focus "is in the interests of the public primarily for reasons of safety but also because of the extensive investment New Zealand has in the education of medical practitioners, and the need to provide a proper quality service for all New Zealanders". ^[12]

'No fault' compensation for medical misadventure

These regulatory initiatives were preceded 20 years earlier by novel accident compensation legislation that covers medical misadventure. Since 1974, persons injured by medical error - the failure by a registered health professional to observe the standard of care and skill reasonably to be expected in the circumstances - have been entitled to state-funded rehabilitation and (if employees) earnings-related compensation. Medical malpractice claims are effectively prohibited by a statutory bar on claims for damages arising, directly or indirectly, from personal injury covered by the Act. Claims for exemplary or punitive damages are available, but the Court has recently confirmed that even gross medical negligence will not lead to such an award in the absence of conscious wrongdoing. ^[13]

The net result is that health professionals are the beneficiaries of a system that looks to the state to compensate victims of medical negligence. Doctors pay modest professional indemnity levies, and are not required to contribute to the cost of state funding for the medical misadventure account.^[14] In the absence of empirical studies, one can only speculate whether the lack of any tort deterrent has had an adverse impact on the quality of health care in New Zealand.

Complaints as a quality improvement tool

It is often assumed that complaints to some form of statutory Health Ombudsman are an effective mechanism not only to resolve individual complaints, but also to improve the overall quality of health care. It is a laudable objective, and an understandable one for those who work as Health Commissioners. After all, it would be rather soul destroying to think that one's efforts are directed solely to the resolution of an endless stream of individual complaints, which may assist those individuals, but have no broader impact. Commissioners find it comforting to believe that health disputes offer a "window of opportunity" to improve health services, and that "this quality improvement function is a major raison d'être of the Commissioners".^[15]

What evidence is there that the Health and Disability Commissioner (HDC) has contributed to an improvement in the quality of health and disability services in New Zealand over the five years that the Code of Consumers' Rights has been in force? The inaugural Commissioner, Robyn Stent, saw the Code as "a quality improvement tool, a blueprint for customer service ^[that] encourages ^[providers] to incorporate its principles into training programmes and codes of practice".^[16] This approach was reflected in the original organisational kaupapa or vision for the Office: "to facilitate improved consumer service and to enhance wellness in New Zealand."

This view was echoed by a leading consumer advocate, Judi Strid, at a National Health Committee Quality Workshop: ^[17]

The Code of Rights developed by the Health and Disability Commissioner's office could not be bettered as a framework for quality. It is consumer-focused and covers the dimensions of quality as well as consumer rights - with the focus on people getting the right advice, the right care, provided in the right manner, by the right person and the right outcome.

I am less convinced of the ability of generic regulation to be an effective framework for quality, let alone to achieve better health outcomes. The restated vision adopted by HDC in 2001 is: "to promote the rights and responsibilities of consumers and providers and to resolve complaints by fair process and credible decisions to achieve just outcomes." If that goal is achieved - in particular the objective that consumers' rights are respected - it will mean that where health care is provided to health consumers, it is of appropriate standard, and sufficient information is disclosed to enable consumers to make informed treatment decisions. Better informed consumers are more likely to make health care decisions that are in their best interests, and if their care is of good quality and well co-ordinated, there may be an overall improvement in health quality. ^[18]

Turning specifically to the role of complaints investigation and resolution in quality improvement, a Commissioner is little more than the ambulance at the bottom of the cliff if all that is achieved is a retrospective analysis of how and why a consumer's rights were breached. Assuming that the individual provider found to have breached the Code responds positively to recommendations to improve the standard of his or her practice, a modest victory for quality at the micro level (in relation to services provided by a single provider) may be claimed. But how does a Commissioner use the resolution of individual complaints to help build the fence at the top of the cliff, and secure improvements in quality at the macro level (in relation to services provided by health providers generally)? The answer lies in the use of reports on Commissioner investigations for educational purposes, and in systemic advocacy on behalf of consumers.

Educational reports

The New Zealand Parliament clearly envisaged an educational role for the Health and Disability Commissioner. The Commissioner is specifically required "to promote, by education and publicity, respect for and observance of the rights of health consumers" and "to make public statements and publish reports in relation to any matter affecting the rights of health consumers".^[19] In practice, this is achieved in the following ways: by media statements on matters of public concern, or on cases which the consumer takes to the media of his or her own accord; by publication of anonymised investigation reports at www.hdc.org.nz, the Commissioner's website; and by sending anonymised copies of reports to the relevant College and/or professional body, the Ministry of Health (as the key government agency for the development of health policy and the funding and auditing of health providers), the Minister of Health, and relevant statutory agencies (such as the Mental Health Commission, in relation to mental health services). Since the scope of investigations, and the "generalisability" of report recommendations, vary greatly, a "horses for courses" approach is taken in determining when, and how, to use a specific report for educational purposes.

Canterbury Health Report 1998 ^[20]

In 1996, senior clinical staff at Christchurch Hospital made numerous approaches to management about concerns over restructuring and the adverse impact on quality. Frustrated by the lack of response, staff went public with their concerns about patient safety, particularly about a number of deaths in Emergency Department. Commissioner Robyn Stent initiated a major investigation into the operation of the hospital and found a number of systems failures that had compromised patient safety. She found a general lack of investment in quality control systems, and a lack of co-operation and communication between management and clinical staff. Junior staff were poorly supervised and were performing procedures with inadequate training and experience. The Canterbury Health Report included a raft of recommendations for change to management and clinical practices at Christchurch Hospital, and a specific recommendation to the Ministry of Health for introduction of a system of credentialling of medical staff in New Zealand public hospitals.

In response to the Canterbury Health Report, a national medical credentialling project was commenced in 1999. In March 2000, the Ministry of Health released the document 'Toward Clinical Excellence',^[21] setting out a framework for the credentialling of senior medical officers. "Credentialling" is defined as:

A process to assign specific clinical responsibilities (scope of practice) to health professionals on the basis of their training, qualifications, experience and current practice, within an organisational context. This context includes the facilities and support services available and ^[that] the service the organisation is funded to provide. Credentialling is part of a wider organisational quality and risk management system designed primarily to protect the patient.

The document notes that credentialling is relevant to all health professionals and states that Ministry's expectation that other professional groups should develop credentialling models based on generic principles but tailored for the competencies of the various professions. Credentialling is stated to be a management responsibility; employers are responsible for credentialling staff on appointment and during employment.

The Nursing Council will work with employers when credentialling of nurses is introduced to ensure that the systems established are well integrated with other components in the competency assurance framework for nurses. It is expected that the HPCA Bill will require evidence of ongoing competence for the issue of annual practising certificates. The new regime will enable the Nursing Council to identify the scope of practice of a practitioner and require evidence of competence to practise in a particular setting. This is similar to the credentialling process described for senior medical officers. ^[22]

Gisborne Hospital Report 2001 ^[23]

In June 2000, the New Zealand Nurses Organisation wrote to the Minister of Health and spoke to the media about concerns raised by nurses employed at Gisborne Hospital. The admitted re-use of syringes by a visiting anaesthetist and the potential risk of disease transmission to 134 surgical patients were widely publicised. In July 2000 the hospital announced that its laboratory in carrying out Prostate Specific Antigen (PSA) testing had made an error. One hundred and seventeen patients were notified of the error and advised to see their general practitioner about the need for re-testing. The positions of Director of Nursing and Clinical Nurse Educator were both vacant leaving nurses without professional leadership at a critical time when major changes were initiated. Against this background, I initiated an inquiry into patient care and quality assurance systems at Gisborne Hospital. In my Gisborne Hospital Report, I found specific breaches of the Code in the operating theatre (due to the re-use of syringes) and in the laboratory (due to failures of quality control and human error in relation to PSA test results). I also found breaches of the duties of care and co-ordination of a hospital provider, due to the failure of Gisborne Hospital to have adequate quality assurance and incident reporting systems in place.

Gisborne Hospital's Incident and Complaint Management Policy was unsatisfactory in a number of respects. There was no differentiation between incidents where harm could have occurred ("near misses") and adverse events where harm did occur. There were no guidelines for the completion of incident reports, no mechanism to track filed reports, and inconsistency about which incidents were drawn to the attention of senior management. Where incidents were reported, in the period under review, lipservice was paid to the concept of root cause analysis, but staff personally involved in the incidents experienced criticism and blame. Incident reporters often received no feedback. Quality and continuity of patient care was potentially compromised by the failure to have an effective incident reporting system. The report included 34 recommendations related to incident reporting and complaints handling, consistent with the approach of the British National Health Service report An Organisation with a Memory,^[24] that analysis of adverse events in health care should focus on root causes, and not simply the proximal events or human errors in isolation of wider processes and systems. A Ministry of Health audit at the end of 2001 confirmed that the report's recommendations have been implemented, and senior management and clinical staff at Gisborne Hospital report improved morale. ^[25]

Systemic advocacy

Findings and trend analysis from resolution of individual consumer complaints enable a Health Commissioner to undertake systemic advocacy on behalf of consumers. For this to occur, the independence and accountability of a Commissioner need to be fostered through statutory authority, dedicated funding and a requirement for reporting to the legislature and the public.^[26] As an independent statutory agency separate from the political and policy decision making process, a Commissioner is well placed to advance the interests of consumers, and to have a significant influence in shaping public policy debate. This may be achieved both by public reporting and media statements, for example to highlight the vulnerability of consumers in nursing homes, and bringing concerns to the attention of Ministers of Health, policy makers, regulators, funders, and professional bodies. The work of the Center for Health Care Rights in Sacramento, California has challenged the view that the primary function of Ombudsman programs should be to assist individual consumers, arguing that this is a bottomless task, with the goal instead being to use examples of individual consumer problems to drive systemic reforms for consumers. ^[27]

Taranaki Healthcare Report 2001 ^[28]

A report on an investigation into the care provided to a seriously injured young man by Taranaki Hospital Emergency Department has highlighted serious safety concerns about New Zealand Emergency Departments. The investigation was undertaken following the death of 19-year-old Tommy Whittaker, whose father complained to the Commissioner. Expert advice from an emergency medicine specialist indicated that staffing levels in Taranaki Hospital fell below international standards and that similar staffing problems existed in Emergency Departments throughout the country.

In 1997 Taranaki Hospital had one medical staff member, often a first year house surgeon, rostered in charge of all departments except obstetrics between 10.30pm and 8.00am. Ideally such cover should be provided by a third year or, at a minimum, second year house surgeon. The hospital failed to provide its staff with adequate guidelines for neurological observations: observations were carried out hourly, rather than half hourly which is the national and international standard. A system for staff to contact on-call registrars or consultants for advice was in place but no guidance was given as to what staff should do if the on-call staff member failed to respond as happened in this case.

The Taranaki Healthcare Report recommended that the Ministry of Health review the staffing levels and competence of Emergency Department staff. Following widespread media publicity, the Australasian College of Emergency Medicine called for New Zealand Emergency Departments to be brought up to international standards.^[29] Emergency Department experience is important for junior doctors, but they need careful supervision and should not be left in sole charge. The reality of staffing shortages, particularly in rural areas, may mean that international standards are still some way away for some departments. However the report has prompted an audit of Emergency Departments by the Ministry of Health, which specialists expect will lead to improved care.

Climate control

The response to adverse events in health care in New Zealand has tended to be characterised by a climate of blame. As Commissioner I can contribute to improve patient safety by fostering a change to a climate of safety that protects patients and supports health professionals. All too often, when something goes wrong with a medical procedure, people search for a culpable individual to shoulder the blame. The traditional focus of professional and legal systems has been the individual practitioner. A guilty individual makes a better headline than a flawed system. Obviously we still require effective mechanisms for dealing with individual clinicians whose actions display recklessness, incompetence or malice. Such individuals must be held to account for their actions.

At the same time, we need to recognise that few adverse events are due to incompetence or malice, and that while human error plays a role in many adverse events, it is usually only the final link in a chain of interconnected problems. Most errors are attributable to the actions of competent professionals, practising in health care environments that are poorly designed to prevent errors and mitigate their consequences. Blaming the individual practitioner in this situation does nothing to prevent similar adverse events from occurring in the future.

A culture of blame

A focus on finding individuals at fault when things go wrong is a key feature of a culture of blame. In this environment errors are covered up and the root causes of errors are not identified, allowing the same events to reoccur. Medical procedures remain unsafe, and when things go wrong again the outcry from the public and the media fuel demands for individual accountability, and the cycle of fear renews itself.

In a Commonwealth Fund study in the year 2000, 46% of New Zealand specialists reported that they were either discouraged or not encouraged to report medical errors, compared with 44% of United States specialists.^[30] It is remarkable that New Zealand appears to have a similar trend of under-reporting to the United States, given the much greater potential for malpractice liability in North America. Significant improvements in patient safety can only occur when this cycle of fear is broken and replaced with a culture of safety.

A culture of safety

In order to move forward from this situation we need to foster the development of a culture of safety. We need to accept that some error is inherent in all human activity, and we must design and implement systems that limit the incidence and adverse consequences of human errors.

Unsafe systems create latent sources of error - "mistakes waiting to happen". In Peter Davis's^[31] study, systems errors were involved in nearly 30% of adverse events. If a nurse is exhausted at the end of a shift, subject to unrealistic time pressures in assessing a patient, or expected to be in two places at once, these are faults of the system, not the individual. Other examples of systems errors include inadequate training or supervision, delay in the provision of services and lack of protocols.

A culture of safety addresses these issues, while still providing mechanisms for responding to problems with individuals. The aim is not to replace a blaming culture with a blameless one, but rather to have a just system, where the root causes of errors are analysed and addressed.

In a culture of safety errors are acknowledged, discussed and analysed. It is safe to admit to having made mistakes and to share the learning from them with others. Medical practice becomes safer, and public confidence improves, leading to support for further quality improvement activities. The delivery of health care is neither an exact science, nor is it foolproof.^[32] Error is an important process in learning and, so long as it is recognised and disclosed, is a creative process providing opportunities for improvement in medical practice. ^[33]

Setting the scene for human error

A recent orthopaedic case in a public hospital^[34]

illustrates how a combination of events can set the scene for human error to occur. Six factors were identified as contributing to the errors made by nursing staff. The case involved complex, elective spinal surgery on a 12-year-old girl, which did not start until after 5:00pm. The surgery had to be performed in the eye theatre as the orthopaedic theatre was being used for an emergency case. On several occasions during the surgery the circulating nurse had to leave the theatre to retrieve equipment. This left only the surgeon and the scrub nurse who was doubling as the surgical assistant in the theatre. There were two wound sites involved in the operation and both nurses were working overtime. Despite not having completed the final instrument and swab count at wound closure, both nurses subsequently signed documentation indicating that the count had been carried out and was correct. In fact, two swabs had been left in the patient requiring surgical removal and drainage of the wound to clear an infection that developed because of the retained swabs.

Although the nurses were found to have breached the Code and were accountable for their omissions, their employer was also found in breach for allowing the situation to develop where staff were expected to perform safely in an environment with the circumstances stacked against them. I have been criticised for the implications of my recommendation that the hospital review the circumstances in which elective surgery is carried out, to ensure that adequate resources are available to provide an acceptable standard of care.^[35] This is a classic case of competent professionals making a basic error when working under pressure without adequate resources, undertaking surgery that could have been rescheduled to a time when a more appropriately equipped theatre, a surgical assistant and fresh nursing staff were available.

The reality: responding to the 'public's hue and cry'

As described earlier, New Zealand has a regulatory system which should promote a culture of safety. We have a system that is rehabilitative, rather than punitive; one that seeks to protect patients yet support doctors. It includes a number of features consistent with modern approaches to reducing error and improving safety.

Yet the system is perceived to be failing both patients and health professionals. On the one hand, local doctors believe they are practising in the most hostile environment in the Western world, in a country obsessed with safety. On the other hand, we are faced with a gloomy picture of the quality of health care and the effectiveness of complaints mechanisms.

Recent major public reports have highlighted under-reporting of abnormalities in the nation-wide cervical cancer screening programme,^[36] substandard care at a public hospital,^[37] and mishandling of investigations into adverse medical events.^[38] A nation-wide study of public hospitals showed that 13% of admissions were associated with adverse events.^[39] Complaints about health professionals are at a record high, and injured patients find the complaints process "confusing, cumbersome, difficult to access and costly, both financially and emotionally".^[40] Confidence in the ability of the New Zealand health and legal systems to respond to concerns about practitioners and systems found wanting is at an all-time low. The public sees medical professions that are shielded from damages claims for negligence, reluctant to blow the whistle on errant colleagues, and slow to discipline substandard members; and a public health system that underfunds public hospitals and screening programmes, and fails to monitor and evaluate the quality of care delivered. Worse, where the system does produce relevant data, there is often no follow-up. The situation has been described as a "medical emergency". ^[41]

Unless effective solutions can be found, we may be doomed to a cycle of public inquiries driven by political responses to media campaigns that fuel (and feed on) the public's "hue and cry"^[42] for medical accountability.

A way forward

A simplistic solution would be a return to the right of injured patients to sue, and a harsher medical disciplinary system. This would be short-sighted. Medical malpractice litigation would inevitably prove a forensic lottery for patients, drive up medical insurance premiums, and lead to defensive medical practices. Nor is there any evidence that public floggings of delinquent professionals would deter others, or lead to an improvement in health care.

New Zealand already has sound regulatory levers. They should be made to work, notably by ensuring that relevant information is shared between central agencies handling medical complaints. External complaint mechanisms need to be accessible, flexible (to avoid duplication of inquiries), and appropriate (reserving the Commissioner's jurisdiction for allegations that warrant further investigation).

The public, too, has a role to play. It may be time to reconsider whether changes in societal expectations, and the ease of making a complaint (dial 0800-11-22-33) are fuelling a culture of complaint. The right to make a complaint - the quintessential 1990s' right^[43] - needs to be exercised with some sense of responsibility.

Finally, external controls must be underpinned by "a functioning internal morality".^[44] The medical and nursing professions should be leading the calls for adequate state-funded compensation for medical misadventure victims; reporting the ways in which quality assurance activities are improving health care; proving that remedial mechanisms are not simply window-dressing; and, in appropriate cases, accepting responsibility for their role in individual and systems failures. It is time for the moral voice of medicine to be heard. I applaud the work of the Joanna Briggs Institute in identifying and disseminating evidence of best practice to nursing professionals as an example of the types of initiatives that will lead to improvements in the quality of nursing care.

Conclusion

Translating patients' rights from slogans into effective regulatory levers for improving the quality of health care remains a significant challenge. Empirical research is needed to evaluate the effectiveness of health complaints mechanisms. As noted by one United States commentator, "the ultimate test of these protections is whether they help lead to an improved health care system, not whether they satisfy established constituencies in the short run".^[45] The jury is still out on whether legislated patients' rights will prove to be an effective tool for quality improvement in New Zealand, but there are some promising signs. The bottom line is that resolving complaints in a constructive way is in everyone's interests.

Reference:

^[1] Cartwright S. The Report of the Cervical Cancer Inquiry. Auckland: Government Printing Office, 1988.

^[2] The Health and Disability Commissioner Act 1994, s 6.

^[3] The Code is set out in the Schedule to the Health and Disability Commissioner (Code of Health and Disability Services Consumers' Rights) Regulations 1996.

^[4] Rights 4(1), (2) and (5). A theme of the Institute of Medicine's recent Crossing the Quality Chasm report, which calls for the overhaul of the US health care system, is the need for providers to focus on co-ordination, teamwork, and communication.

^[5] Non-identifying reports are published on the Commissioner's website, www.hdc.org.nz.

^[6] Brandon W. Complaints against Medical Practitioners. NZLJ 2001; 249-252, 256.

^[7] Personal communication to the author, February 2002.

^[8] The Nurses Act 1977, s 11.

^[9] Nursing Council of New Zealand, February 2001 Newsletter,

^[10] Memorandum to Cabinet Committee on Education and Health, Health Professionals' Competency Assurance Bill - Complaints and Discipline Provisions,http://www.executive.govt.nz/minister/king/

^[11] The Medical Practitioners Act 1995, s 3.

^[12] Parry v Medical Practitioners Disciplinary Tribunal (District Court, Auckland, 30 May 2001), para 85.

^[13] Bottrill v A (Court of Appeal, CA 75/00, 13 June 2001); noted in NZLJ 2001; 233-235. The decision is under appeal to the Privy Council.

^[14] Collection of medical misadventure premiums from registered health professionals is provided for in the Accident Insurance Act 1998, ss 296-298, but has not occurred in practice.

^[15] Wilson B, "Health Disputes: A 'Window of Opportunity' to Improve Health Services" in Freckleton, I, and Petersen, K, (eds) Controversies in Health Law (The Federation Press, NSW, 1999) 179. See also Horvarth, who notes that health complaint watchdogs do not merely settle individual complaints but, in so doing, improve the standards of care across health services (ibid).

^[16] Report of the Health and Disability Commissioner for the year ended 1998 (Health and Disability Commissioner, Auckland, 1998) 5.

^[17] Report of National Health Committee Quality Workshop, Wellington, 21 February 2001 (Ministry of Health, Wellington, 2001).

^[18] Health quality may be defined as the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with professional knowledge. Lohr K, (ed) Medicare: A Strategy for Quality Assurance (National Academy Press, Washington DC, 1990).

^[19] The Health and Disability Commissioner Act 1994, s 14(1)(c), (d).

^[20] Canterbury Health Report 1998 .

^[21] Toward Clinical Excellence: A Framework for the Credentialling of Senior Medical Officers in New Zealand (Ministry of Health, Wellington, 2001).

^[22] Robyn Woodward, Nursing Council of New Zealand, Towards A Competency Assurance Framework for Nursing, 2001, 10.

^[23] Gisborne Hospital Report 2001 .

^[24] Department of Health, London, The Stationery Office, 2000.

^[25] Personal communications to author, November 2001.

^[26] Willcox S. Consumer Protection in Private Health Insurance: The Role of Consumer Complaints. Washington DC: 2000 (unpublished report to the US Department of Health and Human Services) 3.

^[27] Willcox S. Consumer Protection in Private Health Insurance: The Role of Consumer Complaints. Washington DC: 2000 (unpublished report to the US Department of Health and Human Services) 128.

^[28] Taranaki Healthcare Report 2001 (www.hdc.org.nz 98hdc13685)

^[29] "Newly graduated doctors should not be left alone in New Zealand's emergency departments" (Media release, New Zealand Faculty of the Australasian College for Emergency Medicine, 27 February 2001).

^[30] "Doctors in five countries see decline in quality of care" (Media release, The Commonwealth Fund, 12 October 2000).

^[31] Davis P et al. Adverse events in New Zealand Public Hospitals: Principal Findings From a National Survey. Ministry of Health Occasional Paper No3, Wellington December 2001.

^[32] Poutasi KO. Review of Part VI of the Medical Practitioners Act 1995. Report to Minister of Health 1999, 4.

^[33] Jamieson M. Complaints - A Doctor's Perspective. Brookfield Medical Law Symposium, 11 June 1999.

^[34] www.hdc.org.nz 99HDC12195

^[35] G Phipps, "Safety concerns with surgery after hours" NZ Doctor 5 Dec 2001, p32

^[36] Duffy AP, Barrett DK, Duggan MA. Report of the Ministerial Inquiry into the Under-reporting of Cervical Smear Abnormalities in the Gisborne Region. Auckland: 2001 (www.csi.org.nz).

^[37] Health and Disability Commissioner. Gisborne Hospital 1999-2000: A Report by the Health and Disability Commissioner. Auckland: 2001 .

^[38] Cull H. Review of Processes Concerning Adverse Medical Events. Wellington: 2001 (www.moh.govt.nz).

^[39] Davis P et al. Adverse events in New Zealand Public Hospitals: Principal Findings From a National Survey. Ministry of Health Occasional Paper No3, Wellington December 2001.

^[40] Cull H. Review of Processes Concerning Adverse Medical Events. Wellington: 2001 (www.moh.govt.nz), p 15.

^[41] The Dominion, Editorial, 26 June 2001.

^[42] Parry v Medical Practitioners Disciplinary Tribunal (District Court, Auckland, 30 May 2001), para 85.

^[43] Affirmed in right 10 of the Code.

^[44] Paul C. Internal and external morality of medicine: lessons from New Zealand. BMJ 2000; 320: 499-503.

^[45] Neil Weisfeld, Executive Director, New Jersey Medical Association. Personal communication to author, March 1999.