In recent months, there have been a number of high profile cases of medical error resulting in harm to patients. Today I’ve invited Dr Mary Seddon, the Clinical Director of the Centre for Quality Improvement at Ko Awatea, to blog with me on CMDHB’s attitude to errors and patient safety. While we all work hard to provide the best quality of care to each patient every day, I think it’s vital to be clear about our organisation’s standpoint on this so that we can work towards a culture which supports staff to do their best.
Firstly, it’s important to distinguish an error from a violation. A violation is a deliberate deviation from safe operating practices, procedures, standards or rules. A violation involves an individual making an active choice and will be dealt with accordingly through Human Resources.
An error, on the other hand, is when you are trying to do the right thing but actually do the wrong thing. Errors aren’t intentional, they don’t improve through punishment and they’re hard to predict. Usually they come about through a fault of the system. If somebody else could make the same mistake, it’s a systems error.
How we respond to errors is vitally important. The tendency can often be to place blame on the staff member involved. However the danger in this approach is that it discourages staff from reporting errors or communicating openly for fear they will be blamed and punished. Even if individuals are identified and removed, the cause of the error usually remains unidentified and the risk that the error will happen again remains.
What we need to do if something goes wrong is pull back from the instinct to place blame and instead think more deeply about the contributing factors. We need to think about how the system got us to where we are and where the faults in it lie. We designed the system to deliver healthcare as it does, which also means we can redesign the system to address the likelihood of errors occurring. In other words, it’s the system we have to change not the people who work with it.
The reason we need to look at the system rather than the individual is because error is an attribute of being human. To quote Don Berwick, former President and CEO at Boston’s Institute of Healthcare Improvement, ‘so long as healthcare involves humans, it will never be free of errors. But it can be free of injury.’ To counteract human error, we build defences into the system to ensure that it never reaches the patient. We build safety in, such as with the surgical check list or the central line associated bacteremia work currently underway. These are trusted system changes that will help save lives. Unfortunately, these defences also have weaknesses in them and it is these we need to eliminate.
On the flip side, though, we don’t want to give people a ‘get out of jail free’ card. As we’ve mentioned, this approach is about errors, not violations. Individuals are still accountable for outcomes they can control where choice and intention are involved.
At CMDHB, we have a ‘Just Culture’. This means an expectation of high quality individual performance but open disclosure should an error occur. In this case, we will acknowledge the error, apologise to the patient and their family, and commit to investigating the error and sharing learnings from it. All of this requires a culture in which people feel empowered to report errors and make suggestions on how to fix them. One of the motivations for doing this post was reading about a situation at Beth Israel Deaconess Medical Centre in Boston where, after a case of wrong site surgery, the chief surgeon went straight to the CEO to openly communicate about it. That ability to be open and to communicate well is critical to the kind of culture we need to foster at CMDHB.
With Mary, I want to make it clear that we will always use the ‘Just Culture’ framework for analysis when something goes wrong. Should an error happen in our hospital, we want every member of staff to feel able to come forward and talk about it openly, and every manager to reinforce this culture. All of us, including myself as CEO, are accountable for this – it is not just in the realm of clinicians. How each of us responds to medical error determines our organisational culture and the ability we have to improve patient safety.
Dr Mary Seddon and Geraint