The tendency to assign blame when mistakes occur is inimical to an environment in which we hope learning and improvement will take place. But there is some need to hold people accountable for egregious errors. Where’s the balance?
Here’s an example. Several years ago a patient woke up from orthopedic surgery at my former hospital and asked her surgeon, “Why is the bandage on my left ankle instead of my right ankle?” It was at that moment that her doctor realized he had operated on the wrong leg. He immediately reported the error to the proper people in the hospital. A thorough apology was also offered to the patient.
We realized that there were systemic problems in our preoperative procedures that went beyond this case. Our clinical leaders spent several weeks strengthening our care delivery system to minimize the chance of a similar error in the future.
Upon hearing of this case, one of our trustees asked me what I, as chief executive of the hospital, intended to do to punish the doctor. I replied: “Nothing. He already feels terrible about this mistake. Further punishment does not act as a deterrent in these kind of inadvertent errors.” A senior physician added that if we want to establish an environment that promotes disclosure of errors and near misses, the fastest way to drive reporting underground is to punish someone who has made a mistake.
The trustee replied: “Well, maybe. But in my field, we would certainly punish anyone who violated rules or procedures in this manner, even if by accident.”
His field? Investment banking. I laughed, thinking of how rarely people in that field seem to get punished when they break the rules.
People in the medical field are well intentioned and feel great distress when they harm patients. Let’s reserve punishment for clear cases of negligence. Other errors should be used to reinforce a learning environment in which we are hard on the problems rather than hard on the people.