Our surgical mistake was the result of several factors, not an intentional act. Our follow-up naturally involved questions of system risk and individual responsibility. I asked the Joint Commission consultant where to draw the line between an individual's error and a system failure. She spoke about a blame-free work culture as one that emphasizes system solutions while a punitive culture focuses on individual responsibility. The pendulum, she said, was moving somewhere between these two points.
Two authorities, who will be in Syracuse next week for presentations at the Syracuse Healthcare Quality Forum, recently co-authored an article that addresses this issue. Drs. Peter Provonost and Robert Wachter, writing in the New England Journal of Medicine, say that in the last decade
[m]ost health care providers embraced the "no blame" model as a refreshing change from an errors landscape previously dominated by a malpractice system that was generally judged as punitive and arbitrary. . . . Many health care organizations (however). . . have (since) recognized that a unidimensional focus on creating a blame-free culture carries its own safety risks.They authors discuss a patient safety approach that balances individual responsibility with system risk. This is the "just culture." They identify three types of risk: human error, risky behavior, and reckless behavior. Here are examples:
A decade ago two reports on the health care industry made it clear improvements were necessary in patient safety. These were To Err is Human: Building a Safer Health System and Crossing the Culture Chasm: a New Health System for the 21st Century. In the years since, hospitals have understood how risky healthcare environments can be and how important is systems thinking in reducing the risk.- When I drive through a red light because the sun is shining in my eyes, the traffic risk for which I am responsible is inadvertent -- human error.
- If I drive through the traffic signal because I am in a hurry, I am engaging in risky behavior. In this case, I am choosing to accept the additional risk of a traffic accident as preferable to the consequences of being late for work.
- If I choose to drive through red lights whenever intersections are not busy, then my behavior is not just risky, it is reckless. In other words, I am repeatedly engaging in risky behavior.
As a result, hospitals focused more on safer processes (such as using check lists to prevent central line infections and requiring 100% compliance with the universal protocol to prevent wrong-side surgery). They have also focused on technical support for safe practices (such as making hand washing easier with more conveniently located sanitizers and computer order entry to reduce transcription and handwriting errors).
Such changes have improved patient safety, yet hospitals are still not as safe as they should be. Drs. Wachter and Provonost challenge us to create a just culture by a better balance between process and technology changes (system safety) and the importance of following safe practices consistently (accountability):
[W]e have shuffled this issue (the balance between a blame-free and an accountable culture) to the bottom of the deck, preferring to work on easier, less contentious safety activities, such as computerization and checklists. It is time to raise this topic to the top of our agenda.These are thoughtful observations from speakers we will have the opportunity to listen to next week. The Syracuse Healthcare Quality Forum is free for healthcare professionals.
And there is still time to register here.
