Regular readers will recall that my posts about a botched kidney transplant at UPMC were harsh with regard to the center's decision to punish a nurse and doctor when it was evident from the start, and now confirmed, that the problems there were systemic in nature. Perhaps the folks at UPMC should take a leaf out of the book of Dr. Mary Seddon and CEO Geraint Martin of the Counties Manukau District Health Board in New Zealand.
In a post entitled "CMDHB's Attitude to Errors," the authors note:
[I]t’s vital to be clear about our organisation’s standpoint on this so that we can work towards a culture which supports staff to do their best.
Errors aren’t intentional, they don’t improve through punishment and they’re hard to predict. Usually they come about through a fault of the system. If somebody else could make the same mistake, it’s a systems error.
How we respond to errors is vitally important. The tendency can often be to place blame on the staff member involved. However the danger in this approach is that it discourages staff from reporting errors or communicating openly for fear they will be blamed and punished. Even if individuals are identified and removed, the cause of the error usually remains unidentified and the risk that the error will happen again remains.
What we need to do if something goes wrong is pull back from the instinct to place blame and instead think more deeply about the contributing factors. We need to think about how the system got us to where we are and where the faults in it lie.
I was pleasantly surprised to learn that the experience at my own hospital helped contribute to this understanding:
At CMDHB, we have a ‘Just Culture’. This means an expectation of high quality individual performance but open disclosure should an error occur. In this case, we will acknowledge the error, apologise to the patient and their family, and commit to investigating the error and sharing learnings from it. All of this requires a culture in which people feel empowered to report errors and make suggestions on how to fix them. One of the motivations for doing this post was reading about a situation at Beth Israel Deaconess Medical Centre in Boston where, after a case of wrong site surgery, the chief surgeon went straight to the CEO to openly communicate about it. That ability to be open and to communicate well is critical to the kind of culture we need to foster at CMDHB.
Congratulations to the folks at CMDHB!
Dear colleagues at UPMC:
The flight from Pittsburgh to Auckland takes about 20 hours. Well worth the trip, I'd say.
I particularly like these:
ReplyDelete--"Errors aren’t intentional, they don’t improve through punishment and they’re hard to predict."
--"If somebody else could make the same mistake, it’s a systems error."
I'll also repeat the line that Jim Conway (of IHI fame) says he's used hundreds of times:
“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.”
And that is from a man whose mother WAS killed by a medical error.
I hope the leaders at UPMC can see their way through the apparent criticism, and glimpse a future where they simply won't have the need to decide whom to punish, because systems have improved.
Please, all here, if we believe the leaders themselves made an error, let's apply the same thinking to them. Let's hope they can say: "On second thought..."
Slightly off-topic here but did you see this story in yesterday's Atlanta Journal-Constitution? http://www.ajc.com/news/hospital-mistakes-kept-secret-1233859.html
ReplyDeleteHow coincidental that this commentary entitled "A Blueprint for Patient Safety" by Dr. Lucian Leape was 4th on the 'most emailed' list of the Boston Globe today (just behind the Red Sox):
ReplyDeletehttp://www.boston.com/bostonglobe/editorial_opinion/blogs/the_podium/2011/11/_by_lucian_l_leape.html?p1=Well_MostPop_Emailed6_HP
If UPMC doesn't want to read the entire report, just absorb this pearl:
"That’s precisely why transparency in responding to adverse events is so important. In order to improve the faulty systems, we have to understand them: what went wrong and why. Only by acknowledging errors and investigating them can we avoid them in the future."
nonlocal MD