Medical Errors Report #10

A Four-Year Solution Implementation Study

  Health-care Workers Need to Accept Constructive Criticism

The medical community must be ready not only to accept constructive criticism, but also to learn from other professions. If the health-care industry had been learning at the speed required by other industries, such as aviation, the speed of fixing medical errors would have been faster. Many industries are already changing their model of operation to emphasize employee potential while many in the health-care industry are still using the old authoritarian system. This particular problem has retarded the progress of fixing medical errors. Some managers still believe they have the answers to all problems and nobody knows anything but them. Changing the inner mindset of such managers is a challenge for any institution.

 One of the major sources of errors among health-care workers is the false assumption that we have answers to all the problems. Without realizing it, we sometimes act as though we want to play God instead to treating patients. We refuse to listen to complaints and stage defensive attacks when we are confronted with our own mistakes. I cannot remember how many times emergency room nursing staff came to the lab as if ready to fight because the lab rejected a bad or unlabeled specimen. Nobody knows everything. Sometimes we learn from our patients because they are our priority. Other times, we learn from our own mistakes. We do not learn anything while flexing our own egos. There is no need to be ashamed when we do not know something; instead of making an assumption that may kill a patient, we can find out the correct way from our peers. It is better to be ashamed while asking for help than to withstand the embarrassment and the agony of taking another person’s life due to preventable errors.

 In Frank Davidoff article, “Shame: A Major Reason Why Most Medical Doctors Don’t Change Their Views,” (British Medical Journals 2002;324:623-624 March 16, 2002), he describes how shame is making it very difficult for some physicians to change their views about medical errors. He states that shame is very devastating because it goes to the core of a person’s identity making them feel vulnerable and sometimes degraded. Based on their power position as healers, physicians are more vulnerable to shame.

 Self-Transformation is Needed Before Fixing other People’s Problems

All managers, from technical supervisors to chief executive officers must go through a process of self-transformation if they want to fix medical errors or systemic failures. They need to evaluate and accept their own faults before trying to fix problems created by other employees or the system. In the process of self-assessment during evaluation, we learn to identify our own faults and design self-improvement. If managers are unable to see their own personal deficiencies, working with others to fix systemic failures may be very difficult. Managers’ emotional competence should be measured through the perception of frontline workers. Employees’ emotional competence should be measured by their coworkers. A lot of times, managers do not know how their attitudes negatively affect employees. The way managers approach employees will determine employees’ interest in working to improve the system. Once a manager is in the habit of treating employees badly, that manager is dis-empowering him or herself from being effective. The major process of empowering a manager is to create a culture that empowers employees to not only work efficiently, but to identify systemic failures and design solutions to fix problems.