Leaders fail: The blame game continues

Salem witch trial: No defense possible in this court

If hospitals ever hope to create a culture of continuous improvement, the people in charge need to learn how to help people learn from mistakes rather than blaming them when mistakes are made.  Again and again, we hear stories that indicate a failure to realize this fundamental leadership lesson.

Witch hanging:  The result of hysterical blame for ill fortunes

One case occurred last year, an error regarding a kidney transplant at UPMC, where a surgeon was demoted and a nurse was suspended for what was later diagnosed as a series of systemic problems in the organization. Another had a more tragic turn, when a Seattle nurse committed suicide months after being disciplined for administering a fatal dose to an infant, again in an environment with underlying systemic problems.

I quote myself from the blog post describing that last story:

My regular readers know that my former hospital faced a similar issue following a wrong-side surgery. Would we punish the surgeon and others involved in the case? We decided not to, not because they had suffered enough themselves from the error, but because we felt that a "just culture" approach to the issue would suggest that further punishment would not be helpful to our overall goal of encouraging reports of errors and near misses. The head of our faculty practice put it well:

If our goal is to reduce the likelihood of this kind of error in the future, the probability of doing that is much greater if these staff members are not punished than if they are.

Punishment of those involved in this case also would have diverted attention from the failures of senior management in doing its job. As Tom Botts from Royal Dutch Shell commented about deaths on one of his company's oil rigs:

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.

It also would have diminished the likelihood of widespread interdisciplinary participation in redesigning the work flow in our ORs. By making clear that the error was, in great measure, a result of systemic problems, all felt a responsibility to be engaged in helping to design the solution.

But here we go again.  NBC News reported from Ohio:

A nurse who accidentally disposed of a living donor's kidney during a transplant said she didn't realize it was in chilled, protective slush that she removed from an operating room....

[The hospital] said poor oversight and communication and insufficient policies were factors in the kidney's disposal, which prompted the voluntary, temporary suspension of the hospital's living-donor kidney transplant program and led to reviews by health officials and a consulting surgeon hired by the hospital.

The medical center suspended two nurses after the incident; one was later fired, and the other resigned, the hospital said. A surgeon was stripped of his title as director of some surgical services, and a surgical services administrator put on paid leave has resumed work.

Witch cucking justice: If you survive the dunking you must be a witch

As in the UPMC and Seattle cases, is it possible for anyone working in this hospital to read these three paragraphs and not say, "There but for the grace of God go I"?  Think about how the leadership approach that was employed will drive reporting of errors and near misses underground.

The hospital's actions reflect a failure of the leadership to recognize its role in the problems.  Contrast that with real leaders, like Tom Botts mentioned above, and Paul Wiles, former CEO of the Novant Health system, discussing preventable infants' deaths in one his hospitals:

My objective today is to confess.  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)].

If you cannot see the face of your own relative in a patient, or if you can not see the face of your own son or daughter in the face of a distraught nurse or doctor who has made an error, I suggest that your executive talents would be better placed in other industries.

Marty Makary recently wrote about the persistent level of errors that occur in hospitals, decrying the lack of progress in quality and safety improvement.  When you read stories like this one from Ohio, you have no doubt of one major contributing factor, leaders who don't understand what Wiles has stated so eloquently.