Posted by Bill Sandweg on 26 November 2018.
I have been doing some reading into the issues surrounding attempts to reduce medical errors and thereby reduce the incidence of patients injured by them. Experts who study this problem agree that one of the biggest problems is that health care providers are reluctant to report errors. When errors remain unreported, when malpractice is swept under the rug, the positive changes that come from addressing problems, from understanding what happened and trying to make sure it doesn’t happen again, those positive changes never have a chance to take place.
So why are providers reluctant to admit an error? There are a number of reasons. Chief among them is fear. Fear of admitting a mistake. Fear of admitting failure. Fear of being ostracized for that mistake. Fear of being disciplined. Fear of being sued. All of these are reasonable fears but none of them solve our larger problem of not being able to address the error and do our best to make sure it does not happen again.
Again, those who study these issues say that we need to remove the fear. Our institutions need to work collaboratively and compassionately in a non-adversarial manner to address the existence of errors and to devise ways to prevent them in the future. They argue that institutions that monitor health care delivery, and these include hospitals and medical boards, must move beyond blame but must, at the same time, require accountability. They must recognize that the primary goal is to develop structures, policies and procedures that will prevent repetition of errors in the future.
It is also imperative to recognize that no matter what we do, we remain fallible human beings. As fallible human beings we are going to make mistakes and so are those around us. I often find that a significant medical injury is not caused by a single error committed by a single person. They are almost always the failure of a number of people or systems. For example, a specimen sent to the lab for analysis produces a critical result. If something isn’t done immediately, the patient may die or be badly harmed. The hospital has a policy which calls for such results to be immediately reported directly to the nurses caring for the patient who are then to notify the attending physicians. Someone in the lab fails to notice that the value was a critical one or notices it but forgets to call the nurse or thinks his or her co-worker has made the call. When the lab report comes back to the floor, no one notices the presence of the critical value until it is too late or they fail to immediately notify the attending physician. In this hypothetical situation, there is a policy in place to address critical values. If a patient is injured, it is because human beings failed to follow the procedure. At some point we have to realize that there aren’t enough policies or procedures in the world to overcome the fact that health care is delivered by human beings and that human beings make mistakes.
Although there will always be mistakes, that is no excuse for failing to work to recognize errors when they occur and to ask whether we have done everything we can to prevent them. We are a long way from being able to say that we have done everything we can and the road to that place begins with recognizing and reporting errors when they occur.