Monday, July 07, 2008

A lesson from Tom

I have received many thoughtful comments below about our wrong-side surgical error, but there is one that deserves some special attention. It is from Tom Botts from Royal Dutch Shell, and I repeat it in its entirety here:

Paul: thanks for having the courage and commitment as a senior leader of a large organisation to role model open and honest dialogue when a mistake is made. Surely that is the best way to ensure learning takes place and improve the chances that the same mistake will not be made in the future.

I am a senior executive in the oil and gas industry, and we work incredibly hard to ensure our operations are safe, every day. But sometimes mistakes are made and we have to be aware of systems and behaviours that discourage open and honest dialogue (people fearing there is more to lose than gain by being open). The short term result of transparency is often a lot of second-guessing and finger pointing. But it's important we break through those barriers, as you are doing, and decide to stay focused on the longer term goal of learning and preventing future mistakes.

In my business, we had a tragic incident several years ago where two men lost their lives. We decided to be as open and transparent about the incident as possible and went through a Deep Learning journey, involving hundreds of people, that examined in detail all the root causes that contributed to the accident, and to get a clear picture of the system that produced the fatalities. Even though the two men that were killed could have made better decisions, my senior leadership team and I could find places where we “owned” the system that lead to the tragedy.

It was a defining moment for us when we, as senior leaders, were finally able to identify our own decisions and our own part in the system (however well intended) that contributed to the fatalities. That gave license to others deeper in the organisation to go through the same reflection and find their own part in the system, even though they weren’t directly involved in the incident.

Once you take that step of committing to transparency and learning, it sets a high bar and it is very hard (probably impossible) to take it back. This approach has helped make us stronger and more aware of the impact of our daily decisions. I wish you full success in your learning journey and encourage you to stick with it!

While I really appreciate Tom's point about having the courage to disclose errors, he may overstate the fortitude needed to do that. In fact, one could argue that in today's media environment, it has become more or less standard "crisis management" practice to disclose corporate errors. Admittedly, the medicine and the hospital world is slow to adopt that approach, but it is likely to do so more and more.

The real courage is the one shown by Tom and his team: When we, as senior leaders, were finally able to identify our own decisions and our own part in the system (however well intended) that contributed to the fatalities. Please understand the personal context for him, as explained by our mutual friend Jessica Lipnack:

As head of Shell's UK operations at the time, Tom staked his reputation on safety in this very dangerous industry. A massive campaign ensued. You couldn't walk through a vestibule in any of the facilities without seeing a video about safety. There were signs everywhere. From the largest areas of risk - on the rigs - to the smallest - walking down the hall with a hot cup of coffee without a lid on it, people were encouraged to help one another be more safe. I can recall being reprimanded (in a helpful way) a number of times for not holding onto a railing while climbing stairs, this on dry land in a completely stable building, not even on a seaborne vessel.

Then, unbelievably, two young men died on a rig. They'd gone down into what is called a "leg" of the rig without the proper safety equipment. One was 22, the other, perhaps 30 or so. Very young. Completely unnecessary. Despite everything Tom and his safety group had done, despite training, equipment, and extensive conversation.

The one thing I recall Tom saying is this: He was most surprised by his own faulty thinking, that everything he believed about how something like this could happen was plain wrong, that he had false beliefs about learning, and that he couldn't believe that he'd gotten to that point in his life and been so dead wrong. And this is a person who thinks deeply about organizations and how to change them.

I don't believe we have yet gotten to that point here at BIDMC. Sure, we believe in disclosure and transparency. Sure, we have established superb goals for patient quality and safety. Sure, we have instituted an important program to improve the work place and reinforce the value of every person working here. But these are baby steps along this journey.

When I say "we", I mean myself, our clinical Chiefs, and our senior management team. I don't think we are sufficiently self-reflective yet to question our own underlying assumptions and frameworks about how people learn, how bad habits are erased, and how flexible and thoughtful good work habits are created. The standard to which we should be held accountable by our Boards is whether we will grow to learn the lesson presented by Tom and his colleagues. And will we do it fast enough to avoid unnecessary tragedy in this hospital.


David Szabo said...

I think you are underestimating the difficulty that doctors and nurses have admitting serious errors and the personal courage required. Unlike oil company executives, they cannot practice their professions without a state license. The Board of Registration in Medicine might well convene an investigation of this incident, and the Board is not really interested in transparency or apologies. They are predominantly in the blame and punishment business. Additionally, malpractice lawsuits filed by patients against physicians are much more personal than workers compensation claims claimed against an oil company.

Paul Levy said...

Sorry, David, I don't buy that. Oil company executives are under intense public scrutiny and scrutiny by regulatory agencies at the national and local level, and are also subject to lawsuits of all kinds. The actions Tom undertook were in the context of all of that going on at the same time. If you haven't noticed, lawsuits are often filed against companies and their top executives personally.

And, by the way, BORIM is in fact very interested in transparency and apolgies. Ditto for the state DPH.

Finally, if you make a bad mistake as a doctor or nurse, do you really think the state is not going to hear about it, or that the patient isn't going to figure it out and think about suing you anyway? Those days are over. You'd best help the patient (and yourself) heal by disclosure and apology.

Jim Conway, IHI said...

David is right, disclosure can be difficult and takes courage; we have heard that from clinicians everywhere. The Institute for Safe Medication Practices has produced sobering data suggesting that across the nation clinicians live in fear of reprisal from their state professional licensure boards. At the same time, a multi-year process organized by the Mass Coalition for the Prevention of Medical Errors demonstrated great promise in our state’s efforts to evolve from a culture of shame and blame. Recognized was the need to move to a culture that is focused on what’s right for the patient and family and those who serve them, organized around the principals of a fair and just culture, and supports system level learning and improvement. From the Department of Public Health and the Boards under them as well as the Board of Registration in Medicine, PCAC, and the Lehman Center, we have seen enormous resolve to the create this culture. Paul Dreyer, Nancy Ridley, Jean Pontikas, Stancel Riley and many others are fully engaged and committed. Multiple organizations including MHA and MMS share this goal. Is it fixed yet? No. One of our key learnings at DFCI is captured in the notion “Our systems are too complex to expect merely extraordinary people to perform perfectly 100% of the time. We as leaders must put in place systems to support safe practice.” Will the efforts of organizations like the BIDMC, in the aftermath of error and tragedy, advance this? Absolutely.

e-Patient Dave said...

I just spotted this, and I'm in tears, for multiple reasons. Gotta run - more later.

Bob Latino said...

Dear Paul

Here is a post I made on the Boston Globe site regarding the article on the Wrong Site Surgery at your facility. I thought this may be of interest to you and your team.

"I believe everyone should be empathetic to this situation as it can, and does, happen every day somewhere by well-intentioned caregivers. One thing that I find as an expert in Root Cause Analysis (RCA) is our rush to judgment despite having no or little facts to back up our assertions.

Even in this article the author uses words in quotes such as:

"There was still some last minute 'i's' getting dotting and 't's' getting crossed that MAYBE had people a little bit out of their routine,"

"Sands said that medical workers used a marker to correctly label the side of the patient that should have been operated on but that, SOMEHOW, the surgeon failed to notice the marking."

"I THINK he began prepping without looking for the mark and, for WHATEVER reason, he believed he was on the correct side," Sands said."

Using these words of doubt tells me these are assumptions at this point without validation. This puts an image in people's minds that this IS what happened and they leave the article believing this to be the true case. Certainly at this point these comments are hypotheses, but they are not facts.

People need to understand the full process that triggers such failures to occur. Human decision making, decisions to do or not to do something (Human Root Causes), trigger a series of physical consequences (Physical Root Causes) to occur that are observable. In this case the surgeon took certain actions and the outcomes of those actions were observable. This is a fact (the outcome of the action).

If we stop at this point and just blame people for making a bad decision, that is often referred to as "Witch Hunting" and is counterproductive to the investigative process.

What we should be doing is seeking to better understand why a well-educated and experienced caregiver made the decision they did, at the time they did! This is what is often overlooked in our rush to appease the public and powers that be with a response to the incident.

When we seek to understand human behavior we are looking for the Latent Root Causes which are associated with the organizational systems that influence decision making. These are organizational systems such as our policies, procedures, practices, purchasing habits, training routines, etc.

I think we can agree that the surgeon in this case did not intend for the outcome that resulted. So why did he think he was taking the right action at the time he took the action? Was he overloaded with cases? Was the patient record incorrect? Was he on a double shift and fatigued after working so many consecutive hours? Was the OR off schedule and there was rush to get back on schedule? Was this patient his original case or was the patient handed off to him? I do not know the details but there are many unanswered questions.

That is what needs to be drilled deeper and further understood. Only when we understand the rationale for a decision will we be able to prevent recurrence of the same behavior by that person and others in the future.

In our desire for immediate answers after such undesirable outcomes we feel the need to satisfy an appetite with something, even if it is not proven to be true or not the full story.

I applaud the CEO in this case for making the instant decision NOT to cover up the error and to instead try to learn from it so as to avoid a recurrence. Had he not taken this step we would have not know about it and chances are that there would be a rush to put the outcome to bed quickly, but not a rush to find the true Latent Causes."

Robert J. Latino
Reliability Center, Inc.

Anonymous said...

Paul, CEO BIDMC Re> Priorities
"Reducing infection through better hand hygiene" is important but we should be also looking at cleaning stethoscopes between patients,and deep cleaning patient's bed rails and spaces between occupancies with
ultra violet irradation. It might also prevent pathogen transfer if we irradiate food trucks in the kitchens in the off hours, as well as all ambulance interiors, wheel chairs, litters and other 'touch' surfaces, especially in emergency
services and patient admitting areas.

Pathogen Transfer Prevention Co.
Brookline ,MA

Anonymous said...


I disagree somewhat with your statement that a physician being sued and an oil company executive being sued are analogous. Usually the corporation indemnifies or otherwise supports the executive with legal representation or else just pays the settlement, whereas a physician in private practice is hanging out there alone with just his malpractice insurance - knowing that, after a settlement, no other insurance company will touch him for 5 years or more, and his existing insurance company will raise his premiums into infinity. A single settlement or adverse verdict can mean "death" to the physician in our current environment; hence the vociferous nature of the malpractice dialogue from the physicians' side.