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The Blame Game

“The concept that bad systems, not bad people, lead to the majority of errors and injuries has become a mantra in health care.”

--Leape, 2005

The inherit contradiction between zero tolerance for errors in health care and the inevitability that they will occur has always haunted me both as a nurse and health care consumer. How do we reconcile the need for safety with the fallibility of human caregivers? 

Complications

The Agency for Healthcare Research and Quality (2017) acknowledges that complications in medical care cannot always be avoided. However, nurses are responsible for rapidly identifying and treating client complications if they occur. Failure to recognize complications and intervene for a deteriorating client continues to be a key issue in hospitals nationwide. Rapid response teams, early warning systems and technology have improved our capacity to save the lives of our clients who experience complications that where not present on admission (Duncan et al., 2012). Although there have been clear advancements, we must acknowledge that even one such death keeps us up at night.  

Who’s Fault is it Really?

How do we continue to create a culture of safety? Assigning blame to an individual health care provider does not seem to be the answer. Donaldson (2008) provides a simple example of an intensive care (ICU) nurse who took her client to radiology when his knee struck a fire extinguisher hanging on the wall, resulting in a client injury. The nurse was written up by the manager and was told to be more careful. Has this response made the environment safer for the injured client? Would it prevent something similar from happening to another nurse and/or client? What do you think? I am with Donaldson here; it is an “emphatic no!”

Multiple Factors

To improve safety, we must acknowledge that time and again there are a multitude of factors that contribute to errors and injury. Let’s take the Donaldson case, for example. Why did the nurse have to transport the client by herself? Where was transport? Do we need to change the policy to require that two staff members guide a gurney?  Should the fire extinguisher be placed in a recessed niche? Why was it hung in a position to injure a passerby in the first place? Was there a reason why mobile radiology equipment wasn’t brought to the ICU? After all, this is a seriously ill client. What kind of shape is the gurney in? Is it difficult to steer? We could go on and on (Donaldson, 2008)! 

Let’s continue to move beyond blame and take organizational cues from high reliability organizations (HRO) and create health care systems that learn and apply effective solutions to prevent future errors and injury! 

 

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Agency for Healthcare Research and Quality (2017). Failure to rescue. Retrieved from https://psnet.ahrq.gov/primers/primer/38/failure-to-rescue

Donaldson, M. S. (2008).  An overview of to err is human: Re-emphasizing the message of patient safety. In Hughes, R.G. (Eds.), Patient safety and quality: An evidence-based handbook for nurses. Rockville, MD: Agency for Healthcare Research and Quality.

Duncan, K. D., Mcmullan, C., & Mills, B. M. (2012). Early warning systems. Nursing 201242(2), 38-44.

Leapp, L. L. & Berwick, D. M. (2005). Five years after to err is human: What have we learned? Journal of American Medical Association, 293, 2384-2390.