Medical Errors Report #14

A Four-Year Solution Implementation Study

Occasional Medical Error is Different from Performance-Improvement Problems

The non-punitive approach has been introduced as a way to look at systemic problems in health-care institutions leading to medical errors. Unfortunately, many health-care workers are treating systemic failure as an entity that has nothing to do with them. Some ill-informed articles have suggested that errors are not caused by people but by the mysterious creatures called “systemic failures.” This type of information was reported in an article published a couple of years ago by the Department of Health and Human Services. It is a very erroneous and misleading assumption. People create the system; the same people can make the system work better.

 However there are times when systemic failure leads to errors. This should carefully be differentiated from problems caused by people. Failure of a system should not be blamed on an employee. Sometimes there may be situations beyond a worker’s control. There is a point and time when a worker needs to be held accountable. An intoxicated worker making errors on the job is not a systemic problem. A senile surgeon killing patients is not a systemic failure. An emotionally unbalanced worker going through an emotional trauma and making mistakes is not a systemic problem. Systemic problems are created when the ways the processes are put together lead to errors. We should not be treating systemic problems as an uncontrollable alien force attacking health-care workers and rendering them incapacitated, leading to errors that are killing patients. Even the systems we work with are not accidents of nature, but put together by humans.

 Chopra, et al., reports in his observational study, “A Prospective Analysis Over 18-month Period” (British Journal of Anesthesia, 1992; 68:13-17) that 70 percent of surgical mishaps happen because of human mistakes. One of the challenges facing a manger is to differentiate the errors caused by an employee from the ones that resulted from the way the system is put together.  Balancing the non-punitive action due to problems created primarily by systemic failures with holding an employee accountable for continuous personal failures can be difficult. Managers must therefore, differentiate between handling medical errors through a non-punitive action, and dealing with continuous performance problems.

 Regardless of how some institutions work hard to change employees’ behavior, some will remain untouched because they are unwilling to change. In one situation, a hospital nursing staff was taking blood out of the room and labeling it at the desk. Evidence from this study indicates that the chance of labeling error increases when specimens are not immediately labeled at the patient’s bedside. Despite a continuous campaign, some people continue to take blood specimens out of the room and label them at the desk, increasing the chance of mislabeling them. Sometimes the problem is not fixing medical error, but influencing permanent behavior change. Employees who refused to change despite repeated warnings should be held accountable.

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