My post below and a similar one of the Wall Street Journal Health Blog have engendered a lot of comments about punishment after medical errors. The discussion is important and is not yet complete. Let's expand on the topic here.
Thanks to Don Berwick from IHI who referred me to a recent article by Dr. Charles Denham, entitled "May I have the envelope please." (Journal of Patient Safety. 2008 Jun;4(2):119-123.) Chuck relates the marvelous approach to error used by Jeannette Ives-Erickson at the Massachusetts General Hospital. When there is a screw-up in nursing, she calls the involved nurse into her office and asks one question: “Did you do this on purpose?” If the nurse answers, “No,” then Jeannette says, “Well then it is my fault.... Errors stem from systems flaws.... I am responsible for creating safe systems."
As Tom Botts mentions below and as Chuck reinforces in his article, "When we push the envelope in health care, senior leaders and many clinician often never know about the adverse events because these events are often hidden and masked by the complexity and fragmentation of care.... We automatically fall in a name-blame-shame cycle citing violated policies and ignore the laws of human performance and our responsibility as leaders."
Turning back to Ives-Erickson, Chuck notes, "In a few short moments with a caregiver after an accident, the leader declares ownership of the systems envelope, and the performance envelope of her caregivers, and creates a healing constructive opportunity to prevent a repeat occurrence."
Recognizing that the comments made on this blog and the WSJ blog may or may not be representative of the general public, I was nonetheless impressed by the degree to which people felt that punishment was an essential part of process improvement. It also occurred to me that the easy path for a hospital administrator in this kind of environment would be to punish the wrong-doer, bolt on a new process, protocol, procedure, or requirement, and declare the problem solved. After all, that shows decisive and timely leadership.
There's only one problem. That doesn't work. Or if does, only for a short time or until a new glitch is uncovered.
Many of the comments show to me the level of dissatisfaction with and anger about the health care system in general, and perhaps also individuals' experience with certain "god-like" physicians. But, if those admittedly understandable emotional reactions guide our approach to process improvement, we will not make the kind of progress we need.
Lee Carter, chairman of the board at Cincinnati Children's Hospital -- a national leader in the quality and safety movement -- put it in elegant, all-American Midwest terms: Transparency depends on TRUST....trust that one can report an error without getting whacked. I absolutely agree with your blog in both the lack of punishment for this event and reserving the right to punish for events in the future. If punishment were to be meted out, it should be spread to everyone in the OR who didn't call for a time-out. The point is that it wasn't only the surgeon's responsibility. This is what we are working very hard to spread throughout Cincinnati Children's and we are making slow progress.
Think about it. One of the national leaders says that his place is making slow progress. Let's learn from that. Let's not let our own impatience with the errors that occur cause us to leap to a type of solution that appears easy and direct but that is fundamentally flawed.