Set Up For Failure

Before coming to this camp, I was trying to explain the purpose of this camp to some of my family and friends, and I struggled to find ways to explain why we shouldn’t just blame health care workers when medical errors occur.  Placing blame is such a pervasive method in our society for “solving” problems that I struggled to find ways to frame the issue of medical errors in a new way to help them understand.  Over the past two days, we’ve said over and over again that medical errors are not caused by mean people, and I think that is one of the key phrases I will use in the future in trying to explain this experience.  Medical errors are not caused by mean people.  In fact, the vast majority of the time, the people involved in medical errors were actively trying to avoid medical errors at the time the error occurred. These are incredibly smart, caring people who were trying their hardest not to cause an error, and yet an error still occurred.  And so, if these people are already doing their best to not cause medical errors, then something about the system or environment these people are working in must be contributing to the situation that eventually leads to the error.

Placing blame is not particularly effective at stopping medical errors.  If I accidentally grab the wrong syringe of medication and almost or do kill a patient, you can be certain that for the rest of my life, I would be triple and quadruple checking that syringe before I administer it to a patient.  At that point, I am probably the least likely person to repeat that mistake; my own guilt about the situation is going to be extremely effective at that. Furthermore, reprimanding or firing me doesn’t stop another health care worker from repeating my mistake themselves. Recognizing this as a system problem rather than a personnel problem, i.e. that in the stressful environment of health care, it’s very easy to mistakenly administer the wrong type or amount of medication no matter who you are or how experienced you are, allows you to shift focus and develop system improvements that hopefully prevent anybody from making this mistake again. That is a much more effective change than firing one person.  Couching this shift in approach in the context of how much health care workers care about their patients is a very effective way of explaining this new mind set.