A Case of Regulating the Old…and Maybe Educating the Press?

While more and more efforts are being focused on “educating the young” about transparency, patient safety and high quality healthcare, it is also evident educational efforts need to be focused on the media – both TV and press. An excellent post by Bob Wachter MD highlights how a TV program like House can undermine the importance of professionalism, leadership and team-based care – elements critical to the achievement of safe, high-quality patient care.

Along similar lines, on June 1st the California Department of Health announced that 13 California hospitals had been “assessed administrative penalties and fines totaling $825,000 after a determination that the facilities’ noncompliance with licensing requirements caused, or was likely to cause, serious injury or death to patients.”

For six of the hospitals cited this was their first administrative penalty. For four of the hospitals, it was their second. But for one health system, it was their eighth such offense. What was occurring within this healthcare system that would allow not just one, but eight failures to keep patients safe?

These are all very important breeches of safety that should be shared with the public. However, an article in the Los Angeles Daily News about one of these incidents was quick to point out that a nurse failed to perform an accurate sponge count and then erroneously signed off on the count being correct. The same news story revealed that a doctor had improperly placed the sponge in the first place. I can’t help but wonder what this reporter, or whomever threw these specific individuals under the media bus, knows or understands about the full investigation (or Root Cause Analysis) that hopefully was completed after this patient harm event. Or what this reporter knows about “just culture”.

In a high reliability organization (HRO), the entire OR team, all hospital leadership and the hospital board would be responsible for this error.  According to James Reason, whose body of work in human error and organizational processes is the foundation for system’s change in healthcare, the focus should first be on faulty systems and not faulty individuals. A just culture manages honest mistakes made by good people as a system failure. (See another post by Wachter, On Swiss Cheese and Patient Safety, for more information). Reason’s model also does not allow for a system to take a hit in the name of an individual exhibiting egregious or negligent behavior that causes harm. Those who knowingly violate safety policies and procedures for personal gain must be identified and held accountable for their egregious actions. If hospitals continue to have repeated occurrences of the same medical error, one has to ask how engaged leadership is in the quality/safety mission within their hospitals. Do they ensure the repetitions are not from the same caregivers who do not want, or care, to follow evidenced-based safe policies and procedures?

Regulation by the state of California that institutes administrative penalties and fines to hospitals and health system that put their patients at risk is one way to manage medical error, but there must be culture change that also occurs, or like Reason’s swiss cheese model, it’s only a matter of time before the holes eventually line up once again. Over the last 5 years, CA has collected a total of $8.575M in fines that will now be used for Quality Improvement programs throughout the state, which includes an analysis of the harmful events and how/if they were reported–another tenet of HROs. I would hate to think that culture change in medicine has nothing to do with Reason’s work, or Lucian Leape’s work or Don Berwick’s work–and that it is simply a matter of only making health systems write a negatively reinforcing check every time they have another significant safety event.


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