Stop. Just stop. Everyone makes mistakes. With widespread accusations of repeated errors rampant in the media, it is easy to see how the public may feel the system’s response to the Ebola threat is one big mess. The Liberian patient, Thomas Eric Duncan, should have been identified as a potential Ebola case immediately on his first visit to the emergency ward. He should have been isolated, hospital staff should have donned personal protective equipment (PPE), and the Centers for Disease Control and Prevention should have been immediately involved. If these proper steps had been taken, his diagnosis would have been made expeditiously and Duncan would have received proper treatment. That, of course, did not happen. As a result, blame was dished out liberally–most of it landing at the feet of the hospital. But finger pointing can backfire and lead to even more mistakes being made. Consider how much worse healthcare would be if these mistakes were kept under wraps, as would undoubtedly have been the case as recently as 15 years ago. Hospital culture has since changed to encourage transparency Transparency — especially about errors — is vital to the delivery of quality healthcare, because acknowledging an error gives hospitals the chance to prevent a recurrence. In 1999, the Institute of Medicine (IOM) published its now-famous report, To Err is Human: Building a Safer Health System. It estimated that as many as 88,000 hospitalized patients in the United States die each year from preventable medical mistakes. At the time, this report came as a shock to much of the medical community and lit a fire under healthcare leaders to devise a solution to this problem. Until then, medical mistakes were routinely hidden from both providers and patients; communication about errors mostly happened offline, in locker rooms or on-call rooms. The blame was most often placed on the individual practitioner and, as such, errors were perceived to be embarrassing and remained without ownership. What the IOM report did was remove the burden of blame from individual medical providers and reassign it to the system. An error in drug dosing that in the past might have been blamed on the prescribing physician is now attributed to a system lacking back-up dosing checks by the pharmacist and medication nurse – and rightly so. The IOM report called on the healthcare community to establish mechanisms by which providers would be mandated to report medical errors that would then be analyzed by quality assurance experts in a non-threatening, non-judgmental, and non-punitive fashion. The result was the establishment in hospitals nationwide of Medical Event Reporting Systems that depend on individuals to blow the whistle on themselves and trigger a safe-guarding technique known as root cause analysis to be performed. For every mistake there may be many factors that contribute in one way or another to the bad outcome. However, root cause analysis tries to identify the one undeniable cause for the problem that, once removed, eliminates the chance that particular bad outcome will happen again. It was such a dramatic change in medical culture that it took years for practitioners to believe that reporting their own errors would not be detrimental to their careers. I can vouch for this personally. It has taken more than a decade for providers to accept that medical errors are systems-driven and that only root cause analysis can effectuate positive change. With Ebola, root cause analysis is going to be key to avoid mistakes in the future, but this will require a culture where it is safe to admit to errors. Barack Obama’s appointed Ebola Czar, Ron Klain, will almost certainly be using documented errors to undertake the equivalent of a root cause analysis. By doing so, he will be able to identify change in process that will allow the United States to effectively respond to the crisis. However, this work could be damaged by relentless finger pointing. A blame culture is apropos to pre-21st century locker and on-call room gossip, and can be counterproductive. Front page press coverage of mistakes made by assorted individual players might be seen as evidence of transparency, but it could lead to exactly the opposite: error concealment. Without knowing our errors—every single last one of them–the fight against Ebola will be even harder. More than ever, we need to be encouraging people to self-report mistakes, not humiliate them for doing so.
Posted on: Mon, 27 Oct 2014 16:07:41 +0000
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