And physicians have long been told by the lawyers on the hospital staff that they should never admit to the patient they’ve made a mistake, because that information can be used against them in court.Well, that makes it pretty hard for them to admit to a patient that they’ve made a mistake.A: People are talking more and more about teamwork — helping doctors, nurses, pharmacists, and other health professionals work together better as teams — and about full disclosure of mistakes to patients.And I think that the now very widespread and continuing implementation of safe medication practices has been very impressive.We shouldn’t punish people who report mistakes, but rather we should look upon mistakes as evidence, clues if you will, of a faulty system, and create an environment where people feel comfortable about reporting and discussing them.That kind of a non-punitive environment is essential if we want to get people to do something about preventing mistakes.When people, particularly nurses, make a medication error they are disciplined, but what we’re saying now is that’s not appropriate.Nor is it effective in terms of reducing the odds of a next mistake.
It’s really the first step in creating a culture of safety where everybody takes responsibility.
When something goes wrong, the interest is not in finding out what happened so it won’t happen again, but rather in trying to keep the information from getting out because it will make us look bad.
So there’s much more interest in cover-up than in understanding.
This is of course what Don Berwick [former President and CEO, Institute for Healthcare Improvement] has been saying in another way for ten years: Health care has a number of features about it that are really unhealthy.
For example, there’s been a lot of study of institutional behavior, and institutions can be characterized as learning organizations or progressive organizations — and by other buzzwords — but hospitals tend to be on the dysfunctional side.