I wanted to take a moment to think about our conversation on the central line removal case. We’ve spent time talking about how systems are perfectly designed to give the results they produce. So when we consider the central line case, a systems based approach would say that not having standardized protocols would be one of the primary factors in the outcome that resulted. Going off of that, I appreciated that our discussion was based on identifying the faults we found in the system rather than asking what the intern did or did not do leading up to the events. Saying “this error occurred in part because the documentation on heparin had not been added to the chart yet” is vastly different than saying “this error occurred because X person had not added it to the chart yet,” and I appreciated that the first phrasing was used by most people in our discussion as opposed to operating off a checklist (“did you do X, Y, Z?”) that didn’t technically exist. When I think about this subtle difference, I think about the story of monkeys in a cage that ties into a deeply engrained “it’s always been done that way” mentality in the sense that we may sometimes reinforce terrible norms without thinking about it – and I’m glad that in this area, we are doing everything possible to maintain a systems-based analysis that accepts that we all share responsibility in medical errors that result.
