Taking the Easy Way Out When Errors Occur

Historically in healthcare, when an error occurred we focused on individual fault. It was the simplest and easiest way out for us to make sense of any breakdown in care – find the person or persons responsible for the error and punish them mostly through things like shame, suspension or remediation. Re-train, re-educate and re-policy were the standard outcomes that came out of any attempt at a root cause analysis.  Taking that route was easy because it didn’t require a lot of time, resources, skills or competencies to arrive at that conclusion especially for an industry that lacked an understanding, or appreciation of systems engineering and human factors.  High reliability organizations outside of healthcare think differently, and have taken a much different approach through the years because they appreciate that it is only by looking at the entire system, versus looking to place blame on the lone individual, that they can understand where weaknesses lie and true problems can be fixed. James Reason astutely said “We cannot change the human condition but we can change the conditions under which humans work”.

The following short video is about Annie, a nurse who courageously shares her own story…a story that highlights when we didn’t do it right, but subsequently learned how to do it better by embracing a systems approach that is built on a fair and just culture when errors occur.  A special thanks to Annie and to Terry Fairbanks MD MS, Director, National Center for Human Factors in Healthcare who helps us make sure our health system affords the time, resources, skills and competencies necessary to do it correctly.

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