The Wall Street Journal had an interesting article a few weeks ago about how hospitals respond to errors (New Focus on Averting Errors: Hospital Culture, Mar 16). The article suggests that a shift in the mindset of tackling these occurrences is brewing:
Hospitals are taking what might seem like a surprising approach to confronting the problem: Not only are they trying to improve safety and reduce malpractice claims, they’re also coming up with procedures for handling—and even consoling—staffers who make inadvertent mistakes.
The National Quality Forum, a government-advisory body that sets voluntary safety standards for hospitals, has developed a Care of the Caregiver standard, calling on hospitals to treat traumatized staffers involved in errors as patients requiring care, then involving them in the investigation of what went wrong if their behavior was not found to be reckless or intentional. Just Culture, a model developed by engineer David Marx, stresses finding a middle ground between a blame-free culture, which attributes all errors to system failure and says no individual is held accountable, and overly punitive culture, where individuals are blamed for all mistakes.
The article goes on to discuss the case of Julie Thao, a nurse in Madison, WI, who administered the wrong medication to a woman in labor. The baby survived but the mother did not. As the article presents it, the hospital she worked for essentially threw her under the bus as local prosecutors brought criminal charges against her. The overall case for Thao’s culpability is a little unclear. Yes, she made a mistake and didn’t follow every procedure as she was suppose to but there is evidence that the overall procedures were sufficiently cumbersome that no one followed them to the letter.
To put things a little differently, it is unclear how to apportion blame between the process and the person carrying out the process. Steve Spear has written a few things along these lines (see here for an example). He argues that it is hard to find a more involved and motivated workforce than you have in health care. But you still have mistakes. You have a workforce that is highly trained and motivated so the problem must lie in the processes. The fact that errors are relatively few is only a testament to the skills workers have in battling the system.
In some ways, this is classic Demming quality management stuff. There is some inherent variability in the process and failures are not the fault of the workers but of the system and the managers who designed it. It is a little amazing that it has taken so long for this thinking to penetrate hospitals.