From the President's Desk
To Err is Human
 Tampering
with medical records is about a larger issue: consequences
of truth telling and accountability. The sister of an LPN
who was sent to prison for tampering
with medical records was quoted as saying, "This
one woman’s whole life was shattered by one stupid
record-keeping mistake. She’s going to be forced out
of the profession she loves and she’s damn good at."
Falsifying records is more than a record keeping mistake.
It is a deliberate effort to deceive. Fueled by panic and
fear, healthcare professionals risk their careers because
of fear of consequences. Our healthcare system has punished
people who report errors. For too long, nurses have been
suspended or terminated for making errors. In one hospital
with which I am familiar, the policy was to terminate a
nurse after she reported three medication errors. The Pharmacy
and Therapeutics Committee reviewed every medication error.
One month a total of 6 medication errors were reported in
this 650 bed hospital. The physician committee chair declared
that he wanted to reduce the errors to zero. Neither the
doctor nor the Vice President of Nursing recognized that
the punitive policy of terminating nurses for reporting
errors was encouraging nurses to hide their errors.
When we punish people for reporting
errors, we drive reporting
underground and not learn about the mistakes that are being
made that affect our system. Fortunately, this is beginning
to change in healthcare as the concept of a non-punitive
environment takes hold.
What is the philosophy in your
law firm about mistakes? Are employees disciplined or terminated
for making errors? Are errors viewed as opportunities to
review how your system functions, and as a stimulus for
changing operations to improve efficiency? Did your employee
make an error because instructions were unclear and inadequate
training was provided? Did your associate make an error
because she was working a 12 hour day? Was a critical document
misfiled because you were representing two people with the
same first and last name and do not have a way to differentiate
between the two? Do your support staff feel comfortable
enough to admit to making a mistake without fear of your
reaction? The answers to these uncomfortable questions stimulate
business owners to examine themselves and their systems.
Remember, to err is human, to forgive is divine. To fix
the system to improve it is the mark of an effective team.
For
more information see:
Medication
Errors video by Patricia Iyer
Pat
Iyer discussing medical records tampering on television
Pat
Iyer discussing medication errors on television
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