Paul Levy
Posted 2/21/12 on Not Running a Hospital
An article in amednews.com reports:
[D]ata released in February by the Agency for Healthcare Research and Quality show that most physicians, nurses, pharmacists and other health professionals working in hospitals believe their organizations are still more interested in punishing missteps and enforcing hierarchy than in encouraging open communication and using adverse-event reports to learn what’s gone wrong.
These findings underlie the tragedy in medicine that results in thousands of preventable hospitals deaths each year and untold harm to other patients. Correcting this problem is a matter of leadership, plain and simple. The clinical and administrative leaders of hospitals need to set a different standard.
I note this in my new book, Goal Play! Leadership Lessons from the Soccer Field:
You can see this philosophy in action through an event that happened at Beth Israel Deaconess Medical Center in July of 2008. A patient woke up after orthopaedic surgery and asked her doctor, “Why is the bandage on my right ankle instead of my left ankle?” It was at that moment that the surgeon realized he had operated on the wrong limb. It is impossible to know who was more distraught, the patient or the doctor who realized that he had violated a life-long oath to “do no harm.”
It was quite clear that the hospital’s “time-out” protocol, which was designed to avoid precisely this kind of error, had not been properly carried out. In the weeks following this disclosure, a number of people asked me if we intended to punish the surgeon in charge of the case, as well as others in the OR who had not adhered to that procedure. Some were surprised by my answer, which was, “No.”
I felt that those involved had been punished enough by the searing experience of the event. They were devastated by their error and by the realization that they had participated in an event that unnecessarily hurt a patient. Further, the surgeon immediately reported the error to his chief and to me and took all appropriate actions to disclose and apologize to the patient. He also participated openly and honestly in the case review.
. . . [A] wise comment by a colleague made me realize that I was over-emphasizing the wrong point (i.e., the doctor’s sense of regret) and not clearly enunciating the full reason for my conclusion. The head of our faculty practice put it better than I had, “If our goal is to reduce the likelihood of this kind of error in the future, the probability of achieving that is much greater if these staff members are not punished than if they are.”
I think he was exactly right, and I believe this is the heart of the logic shared by our chiefs of service during their review of the case. Punishment in this situation was more likely to contribute to a culture of hiding errors rather than admitting them. And it was only by nurturing a culture in which people freely disclose errors that the hospital as a whole could focus on the human and systemic determinants of those errors.
Care And Cost 
I couldn’t agree with you more. But this approach needs to commensurately take into account the trauma the patient underwent, which is no less, and indeed more than the surgeon did. You are right, by not taking blame and shame approach you may prevent future events occurring but how do you ensure that all such future harm is prevented in your hospital? For sure, the surgeon who messed up this time will never do so again. But how do you make others realize they are just as susceptible? After all, the protocols were in place when the error occurred in this instance but somehow the surgeon did not follow them. Why would another surgeon who has not yet messed up follow through any more diligently? And what of the patient- you didn’t tell us how she recovered and how the hospital “made up to her” for what happened to her?