Paul Levy extended an open invitation to healthcare colleagues on the New York Times Opinion page in a letter to the editor entitled, Invitation to a Dialogue: When Doctors Slip Up. Here is an excerpt from that letter:
The tendency to assign blame when mistakes occur is inimical to an environment in which we hope learning and improvement will take place. But there is some need to hold people accountable for egregious errors. Where’s the balance?…People in the medical field are well-intentioned and feel great distress when they harm patients. Let’s reserve punishment for clear cases of negligence. Other errors should be used to reinforce a learning environment in which we are hard on the problems rather than hard on the people.
This has been a continued struggle, both spoken and unspoken, for years. As Paul points out, well-intentioned and hard-working physicians, nurses, pharmacists and other care team members come to work each and every day trying to help heal those in need. However, our current health care system fails them (and our patients) when they come to work. The system also fails to create a learning environment where well-intended caregivers can share potential areas of weakness or events because of fear for their own careers. Because the existing culture of medicine has been very slow to change, I have always believed that educating the young was a silver lining of sorts–or a way to rebuild our culture from the ground up. Educational content on open/honest communication with patients and colleagues has been the core curriculum at the Telluride Patient Safety Student & Resident Summer Camps for the last four years, and that has been shared with over 300 resident physicians, and medical, nursing, pharmacy and law student alumni. It was with great pleasure that I read Telluride alum, Stephanie Wappel’s following response to Paul’s NYTimes piece this weekend – one of the few selected from many responses (see additional comments, including MedStar’s Human Factors Engineering Director, Dr. Terry Fairbanks, & myself here):
I was fortunate to attend a conference on patient safety for which Mr. Levy was a faculty leader. I agree that we need to change the culture regarding the disclosure of medical errors. We cannot learn from what we do not know, and what we do not know can seriously harm our patients.
One strategy that has been implemented at my home institution is the celebration of “good catches.” Every Monday, all hospital employees receive an e-mail that features the “good catch” of the week, in which an error was detected and reported before it had the potential to cause harm. Any hospital employee can report these good catches.
They range from a nurse’s realizing she received the wrong dose of medication from the pharmacy to a medical student’s stopping her patient from getting a procedure that the physician thought he had canceled in the new electronic ordering system. Obviously, the institution is also working on discovering how that error occurred to prevent similar ones.
It is no easy task to change a culture, but this seems to be a good start.
Washington, Oct. 16, 2013
The writer is a resident physician at Georgetown University Hospital
The Good Catch Program Stephanie mentions has been a concerted effort of our Patient Safety team at MedStar Health to share some of the learning opportunities that arise on a day-to-day basis in healthcare, celebrate those for their courage to report them, and face them head on versus hiding from them.
If health care is to achieve safety successes seen in other high-risk industries such as aviation, we must learn to balance safety and accountability. For caregivers who knowingly and recklessly violate safe practice, discipline is the right course and much needed. But most errors that lead to patient harm occur because of bad systems or processes, not bad people. Until we can be open and honest about our mistakes, learn from them and support our well-intentioned colleagues, we will continue to struggle.