Making mistakes in health care The provision of health care is a service that involves people, and any organization that has employees knows that mistakes will be made from time to time.
The difference in our sector is that mistakes can involve much more than the loss of dollars or opportunity. They can involve physical or psychological injury to a patient/resident/client or, worse, loss of life.
For that reason, there used to be a simple philosophy of punishment whenever errors were made. If Nurse X gave the wrong medication to a patient and the patient suffered harm, she was fired. It seemed the right thing to do at the time.
We believe no staff comes to work to intentionally harm a patient.
Health care all over North America has been watching other industries find methods that actually reduce human error rather than just push the mistake-maker out the door. We're catching on to the idea that errors at the bedside or surgery table can be the result of a poorly designed system at least as much, if not more, as a flawed human being.
Gradually we are moving toward a philosophy called a Just Culture. The Just Culture looks at both the person who made the mistake and the system he/she works in to understand errors and prevent them from being repeated.
For instance, what if you learned that Nurse X made the mistake after working two shifts in a row because of a staff shortage? Or the medication came from the manufacturer in a bottle that looked almost the same as another, benign medication? Would that make a difference to the punishment you exacted?
What if the same error happened two months ago under the same circumstances and another nurse had been fired? At what point does the system take some responsibility for the errors?
What if an investigation discovered the error occurred after Nurse X partied all night the night before she began the two shifts?
An organization following the Just Culture philosophy would examine all of the evidence available and weigh the responsibility held by both the system itself and the individual.
That's where Sun Country Health Region is moving. We take responsibility for building a safe culture in which our staff members work, and our staff members take responsibility for the pieces they control.
We expect it will lead to a greater willingness on the part of our staff members to be transparent and report errors so as to understand what really happened.
That's the way to make health care safer and be more accountable to the public.
