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Ending kneejerk responses to medical errors


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Rebecca Hendren, for HealthLeaders Media, June 21, 2011

Mistakes are a fact of life. As the Institute of Medicine said, "To err is human." What matters is how we respond to mistakes, which involves putting systems in place to stop errors before they happen and supporting clinicians who make mistakes.

Not long ago, the catch phrase was "no blame" culture, where people talked about non-punitive responses to patient safety incidents. But simply saying "no blame" doesn't take the complexities of medical errors into account. Removing personal accountability from individuals isn't the answer, but neither is a rush to judgment and punishment that we know still occurs too often.

A balanced response that emphasizes individual and organizational accountability is Just Culture, a concept originating in aviation and crew resource management and lately honed by engineer David Marx. The Just Culture process involves purposeful responses to situations that investigate exactly what went wrong and why so as to understand everything, without falling prey to kneejerk emotional reactions that attribute blame.

One organization that has been working on establishing a Just Culture for the last few years is Lutheran Medical Center in Brooklyn. Rosanne Raso, RN, senior vice president, nursing services, says the most important concept of a Just Culture is to remove the emotional response that occurs whenever there is a medical error or a near miss. 

"The old way of doing things was to have a kneejerk reaction and punish people and that doesn't fix anything," says Raso. "You have to investigate and look into why things happened. You can't make any decision or judgment about what happened until you really dig into the whys. You don't know how to fix it until you know what went wrong."

Just Culture emphasizes learning from every event and promoting a culture of shared accountability throughout the entire organization.

"By shared accountability, I mean that the organization is responsible to have good systems that minimize risk," says Raso. "The individual is responsible for their behavior. They are responsible even if they made a mistake."

Raso provides an example. If nurses know the hospital's procedure is to check two patient identifiers before administering medication, then nurses are accountable for doing so. Let's say, however, that an organization uses a flimsy wristband system that is prone to falling off. In addition, there's no way to get another wristband without jumping through five hoops and filling out forms in triplicate. In this case, the organization doesn't have a system to support proper verification of patient ID.

"That's shared accountability," explains Raso. "The staff person is responsible for following safety policies and procedures and for making good judgment. In the end they are responsible for doing the right thing. But the organization is responsible for having systems to support that."

Raso points out that people don't usually break rules intentionally. "So to punish people for breaking rules is not always right because nine times out of 10 everyone is breaking the same rule," she says. "If you have routine violations of a rule, you have to make it part of investigation and have a systemwide corrective action plan. It's usually about systems, not people"

In a Just Culture, organizations perform a thorough investigation following an incident or a near miss, similar to a root cause analysis. It's important that staff are educated about the process or they may fear the investigation is looking for a scapegoat.

"Make it very clear that it's not a witch hunt," says Raso. "Say, this is not about punishing you. We are here to learn what happens so we can fix systems that support you to give best care possible to our patients.'"

The investigation should focus on what happened and why. Was there a system problem, does a process need to be redesigned? Was it a competence issue and does the individual need education or a focused performance review?

If organizations decide a caregiver made a mistake due to risky behavior and needs coaching, care should be taken to make it relevant. Simply admonishing caregivers to "be more careful" is a waste of time. To effect change, coaching should focus on behaviors. For example, coaching a nurse through the process of medication administration and the steps the organization expects nurses to complete each and every time.

"The other thing is that competence is not optional," says Raso. "If you are in unit where you cannot demonstrate competent behaviors for that patient population despite education and coaching, then you can't continue to work there."

It's hard to separate emotions when something goes wrong, but "in a true Just Culture, it's not about the outcome at all," says Raso. "Whether the patient was harmed or whether the error never reached the patient at all, you still use the same principles."

Everyone is responsible for their own actions and behavior. So if the investigation discovers a nurse was reckless or intentionally disregarded important safety safeguards, then the person receives punishment, such as suspensions or termination. However, incidents of intentionally reckless or criminal behavior are rare. Most incidents are completely unintentional and clinicians are devastated after making a mistake.
 
"You can't punish the person more than they punish themselves," says Raso. "There is nothing worse than the punishment that someone who makes a mistake inflicts on themselves."

Source: HealthLeaders Media