Individual or Systemic Blame — What’s Boston Got to Do With It?

David Orentlicher has an interesting post over at the Faculty Lounge discussing insurance studies of cities with the "riskiest drivers" sparking a meditation on medical error reduction system-design in health care.

I, too, think about analogies between driver error and medical error. First, it is useful to do so in the classroom because — simply — most of my students have driven an automobile but many fewer are licensed health care professionals. This means they are more likely to have had experience with their own near misses in the driving context and had reason to ponder poor design and proper allocation of risk and responsibility on the road. Second, it is useful to do so because it allows me to talk about how our cultural values — whether based on individual responsibility and fault or group responsibility and shame — inform our medical-legal system for dealing with medical error.  And, finally, I like to use the analogy to driving risk and responsibility to get my students thinking about how some societies have decided "less is more" in the organization of roadside warnings and guidance and how that might play out in our attempts to reduce medical error.

I like David's post, but it is in the comments that the truth about Boston driving is outed: there we have the perfect storm of a culture of agressive driving combined with congestion enhanced by an inner city road system designed before the automotive era. My days of working in downtown Boston (on Beacon Hill) were filled with remembrances of cars full of tourists usually driven by a shell-shocked driver pulling up to me as I would cross Park, or Beacon, or Tremont to ask me where they might park to walk the Freedom Trail. I would tell them: almost every street here is one-way and legal parking is unbelievably scarce, you may do as the Bostonians do and park illegally or drive back out of the center city to park at a T Stop and use mass transit to approach the central city. But, of course, it was error even to drive into the city before they backed out — incrementally adding to the congestion, pollution, and shortened life span of the stressed-out driver.

Now, what's the medical error equivalent of congestion pricing or rewarding those who don't even contribute to the near occasion of error?