What if hospitals, instead of disciplining employees who make inadvertent and sometimes deadly mistakes, opted to console and retrain such employees? Two programs, "Care of the Caregiver" and "Just Culture," aim to do just that, while a new study in April's Joint Commission Journal on Quality and Patient Safety looks into how simply assigning blame on an individual or the hospital system is often a faulty approach.
Researchers from the Institute for Safe Medication Practices delved into the case of Julie Thao, a nurse at St. Mary's Hospital in Madison, Wis., who four years ago mistook a bag of epidural painkiller for penicillin and hooked it up to the IV line of a teen who was in labor. The epidural was to be administered via spinal injection at a later time, and caused the patient's heart to collapse, ultimately killing her (her baby was delivered successfully). Thao was not only fired by the hospital, but was also prosecuted by the state for criminal negligence.
The researchers concluded that Thao should not have been held solely liable and that the actions taken against her weren't an effective way to prevent similar mistakes from happening. Instead, a series of system flaws, such as inadequate training on a bar-coding system and a lack of rules to prevent fatigue, contributed to the tragedy.
Dr. Charles Denham, a patient-safety expert who wrote an accompanying editorial, said that while Thao should have been held accountable, she wasn't the only one. "It is clear that other nurses might have made the same error due to the social conditions and technical systems in the hospital," Dehnam said.
Programs like "Just Culture," which St. Mary's used after the incident, aim to ensure that not just one entity--either an individual or the system's culture--is held accountable in such situations. Instead, "Just Culture" strives to find a middle ground. Furthermore, the "Care of the Caregiver" standard founded by the National Quality Forum, where Denham co-chairs a committee on safe practices, treats employees who make such mistakes as traumatized patients who also need care. The standard even allows such employees to participate in their own investigations as long as their actions were found not to be reckless or malicious.