Tuesday, February 21, 2012

Reverse the expectation of punishment

An article in amednews.com reports:

[D]ata released in February by the Agency for Healthcare Research and Quality show that most physicians, nurses, pharmacists and other health professionals working in hospitals believe their organizations are still more interested in punishing missteps and enforcing hierarchy than in encouraging open communication and using adverse-event reports to learn what's gone wrong.

These findings underlie the tragedy in medicine that results in thousands of preventable hospitals deaths each year and untold harm to other patients. Correcting this problem is a matter of leadership, plain and simple.  The clinical and administrative leaders of hospitals need to set a different standard.

You can see this philosophy in action through an event that happened at Beth Israel Deaconess Medical Center in July of 2008. A patient woke up after orthopaedic surgery and asked her doctor, “Why is the bandage on my right ankle instead of my left ankle?” It was at that moment that the surgeon realized he had operated on the wrong limb. It is impossible to know who was more distraught, the patient or the doctor who realized that he had violated a life-long oath to “do no harm.”

It was quite clear that the hospital’s “time-out” protocol, which was designed to avoid precisely this kind of error, had not been properly carried out. In the weeks following this disclosure, a number of people asked me if we intended to punish the surgeon in charge of the case, as well as others in the OR who had not adhered to that procedure. Some were surprised by my answer, which was, “No.”

I felt that those involved had been punished enough by the searing experience of the event. They were devastated by their error and by the realization that they had participated in an event that unnecessarily hurt a patient. Further, the surgeon immediately reported the error to his chief and to me and took all appropriate actions to disclose and apologize to the patient. He also participated openly and honestly in the case review.

. . . [A] wise comment by a colleague made me realize that I was over-emphasizing the wrong point (i.e., the doctor’s sense of regret) and not clearly enunciating the full reason for my conclusion. The head of our faculty practice put it better than I had, “If our goal is to reduce the likelihood of this kind of error in the future, the probability of achieving that is much greater if these staff members are not punished than if they are.”

I think he was exactly right, and I believe this is the heart of the logic shared by our chiefs of service during their review of the case. Punishment in this situation was more likely to contribute to a culture of hiding errors rather than admitting them. And it was only by nurturing a culture in which people freely disclose errors that the hospital as a whole could focus on the human and systemic determinants of those errors.


Anonymous said...

It is an outrage that this attitude necessarily persists after so many years of talking about a just culture, etc. As an early reader of your excellent book, Paul, another quote from it comes to mind, from the CEO whose hospital had killed several NICU babies:

"The crux of his entire presentation was this comment: "My objective today is to confess," Wiles said. "I am accountable for those unnecessary deaths in the NICU. It is my responsibility to establish a culture of safety. I had inadvertently relinquished those duties" by focusing instead on the traditional set of executive duties (financial, planning, and such)."

Until CEO's learn to 'own' these errors instead of blaming someone else and firing them, nothing will change. Walk a mile in our shoes.

nonlocal MD

SPigg said...


An important point. However, I think this is somewhat of a grandiose example (obvious error, immediate need to resolve, etc.)

How can you apply the same principles to outpatient services, where possibly even the provider is unaware that they've made a mistake because the end result is not as catastrophic/obvious? That is, what other methods could be utilized to uncover/understand wasteful errors?


Jesse said...

Yes, but...

In a true just culture model, there still needs to be some accountability.

In this case, if the surgeon purposefully prevented the use of the pre-procedure time out, there should be some accountability. Otherwise, you are empowering "bad behavior". That is the crux of the issue: no-one should be punished for normal human error (though they may need some re-training, coaching, or more likely there needs to be a system change), but they should be held accountable for "bad" or inappropriate behavior. The lack of that last, I believe, is one of the reasons that medical staff have been an impediment to improving safety culture.

Paul Levy said...

Excellent points, Jesse. See here for a more full discussion: http://runningahospital.blogspot.com/2008/07/guide-to-just-decisions-about-behavior.html

The idea is that there are certain events that are always blame-free and others that are certain to require disciplinary action. In the former category, we have mistakes that are made when there is no policy or process in place, when the person incorrectly interpreted an ambiguous policy or process, or when he or she was actually following the official policy. In contrast, people can expect disciplinary action when they intentionally cause harm or tamper with the error reporting process (i.e., engage in a cover-up); when they recklessly or intentionally disregard patient safety; or when they repeatedly violate hospital processes, policies, or standards.

But no chart or formula can cover all events. It is appropriate to acknowledge that judgment will be used in the “gray areas,” where someone failed to participate in a patient safety initiative; where the error or near miss resulted from a minor deviation from policy or process; or where carelessness—as opposed to intent—led to a deviation from accepted standards. In evaluating errors within the gray area, we look to see if the act or omission was reckless or repeated, or whether it undermined our patient safety initiatives.