Medical-Legal Topics

The Joint Commission, one of the preeminent bodies that accredits a wide variety of healthcare organizations, is shining a spotlight on the critical role of leadership in reaching a zero-defect level of safety. Although other industries, such as aviation, manufacturing, and energy, have developed safety interventions needed to reach a zero-defect level, health care has not been as successful. We have an incredibly complex system with multiple opportunities for error. I envision patient safety as resting above a safety net. The holes in the safety net range from small to wide.

The Swiss Cheese Model is another way to view patient safety. In James Reason’s model, the holes line up in the system; a patient passes through and is injured. When a series of errors occur, if anyone along the chain of events had done something different, the patient would not have been injured. Those of us who work in the medical malpractice arena can think of cases where this unfortunate cascade of errors has occurred. For example, I worked on a nursing malpractice case involving a man who received the wrong type of blood. Another patient and he had the same name; a mix up of identity occurred. The admissions clerk, laboratory technician, unit secretary, hematologist and several registered nurses were part of the chain. The blood bag was not checked at the bedside with the patient’s identification band; he died as a result of receiving the incorrect blood type.

What does the concept of zero-defects mean in practical terms? I am reminded of the reaction I saw when a surgeon told a patient there was a 1 in 100 risk of a certain complication occurring in the operating room. The patient asked, “What number am I in your total of 100?” It is only human nature to want the other guy to be the one case while we cling to the 99.

Attention to the goal of zero-defects also reveals what risk managers and family members fear: some patient injuries are not reported, starting with the person directly involved in the incident and ranging through leadership. The Joint Commission acknowledged this reality: “Leaders must consistently make safety a top priority in their decision-making. Safety must be supported at all levels of the organization and by both administrative and clinical leaders. Unfortunately, patients and health care staff may perceive a considerable difference between what leaders say and what is actually occurring—for example, when leaders do not support the reporting or managing of errors for fear of litigation.” In reality, it it’s the hiding and cover-up that sends some patients to plaintiff attorneys so that they can get answers to the question of what went wrong.

I recall sitting in a hospital Pharmacy and Therapeutics Committee meeting some years ago while the director of nursing had to explain each of the 6 medication error incident reports that had occurred that month in a 600 bed hospital. The physician said, “I want there to be zero errors!” I pulled the vice president of nursing aside and said, “We’re not getting accurate reporting. Statistically, there should be a much larger number of incident reports.” She disagreed. However, the nursing department disciplined nurses who made errors. The policy was to terminate the nurse after three errors had occurred. Not surprisingly, nurses were reluctant to report errors, as they functioned within a culture of fear.

That culture of fear is being replaced by a culture that focuses on just handling of staff after an error occurs. The Joint Commission addressed this inherent conflict in the new Sentinel Event Alert: “Actions taken in response to adverse events can be administrative or disciplinary as well as safety-related. These actions must not only be fair, they must be perceived to be fair; otherwise, future reporting of events may be discouraged. Such an approach is consistent with a culture of safety and is symbolic of a ‘just’ culture. A just culture is not wholly blame-free. It is one that has a clear and transparent process for evaluating errors and separating egregious unsafe acts from the small errors that people make every day, because we are human. The large errors are considered for disciplinary action with a set of guidelines that are applied equitably and consistently across all groups within the organization. It is the small errors that should not be cause for blame or punishment but should rather be recognized as important sources of information about system vulnerabilities.”

Leaders have critical roles to play in supporting staff who report errors and in making the changes needed to plug holes. The Joint Commission’s Alert is a needed directive to add more light to a subject that can hide in the shadows of the corner.

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