Day 3 Reflection: Culpable to Blameless

Today’s sessions tied together a lot of information that we’ve seen in the past few days. The focus today was on just culture, which ensures that a system can be both fair and accountable. Both aspects are important: people need to be held accountable if they are truly being negligent or malevolent, but they should not be judged unfairly if the system is set up to fail. I was really fascinated by the Unsafe Acts Algorithm, which is an extensive tool that can be used to show the range of outcomes for a healthcare worker in question. There are cases that are truly culpable (a person should be held accountable), truly blameless (the system was not fair), and a gray area that can vary on a case-by-case basis. This algorithm reminded me of an idea I had earlier this week.

Just as we compared healthcare systems to the aviation industry, I believe that a comparison should be made to another system that is currently facing a public crisis in our country- the police system and fatal police shootings. Now, let me preface by saying that I am in no way an expert on either patient safety or policing. While there are some obviously very different underlying issues that affect both systems, there are some similarities that it wouldn’t hurt to discuss.

  1. The main interest of both the police force and healthcare providers is to protect the public.
  2. The situations where the public is instead harmed is often attributed to communication errors. In healthcare systems, those communication errors can be between healthcare workers themselves and/or between patients. In unjust police shootings, there are sometimes miscommunications between the police officer and the victim, such as in the case of Philando Castile.
  3. Medical errors and police shootings both occur in situations where the situations escalate very quickly. People working in both situations are caught unawares and react out of fear instead of reacting as they had been trained. In crisis situations, we need to train ourselves to not respond from our implicit biases- race or hierarchal authority. We need to demand better training and more simulations to help retrain both healthcare workers and police officers so that they can stay calm in these situations.
  4. After an error, both police departments and hospitals tend to hide behind lawyers and shroud themselves in secrecy. This lack of transparency only causes the public to distrust these systems more.
  5. While some of these “errors” are solely due to culpable people who meant harm and should be punished, we have to start wondering if these errors have been built into the systems and causing the same outcomes to occur repeatedly. The point of the “substitution test” in the algorithm emphasizes this point. If someone else could also make the same decision and cause a bad outcome (an unwarranted death by a police system or a hospital), then that issue will undoubtedly occur again.

As I said before, there are many differences between these two issues, both of which are nuanced issues. However, I believe that both systems would benefit from a review into how “just culture” can be better implemented.