ACHE 2017: Fault is the patient safety 'F-word’

Doctor and nurses wheeling patient in gurney through hospital corridor
Healthcare organizations shouldn't blame doctors when medical errors occur. (Getty/Sam Edwards)

CHICAGO—Blaming physicians or staff for medical errors is the wrong approach, says patient safety expert James P. Bagian, M.D.

“Fault is the F-word in medicine,” Bagian, director of the Center for Healthcare Engineering and Patient Safety at the University of Michigan, told healthcare leaders at the American College of Healthcare Executives’ 2017 Congress on Healthcare Leadership on Monday.

Instead of pointing the finger, healthcare leaders need to look at the reasons a medical error occurred and make changes to keep it from happening again, said Bagian. “Human error is never the cause,” he said. For instance, if a person was not following rules and procedures, you need to look at why they weren’t following them.

Healthcare leaders should look to the airline industry, which plans for human error and builds processes to prevent issues, said Bagian, a former astronaut who helped investigate the Challenger disaster. Here are some of his tips for how healthcare leaders can make patients safer:

Set a goal that no patient is inadvertently harmed, rather than that nobody will make healthcare errors. No one comes to work in the morning planning to make an error, he said. Organizations can’t count on people being perfect. “That’s a fool’s bet,” he said.

So instead of telling a nurse to be more careful, organizations have reduced medication errors by using a barcode system.

Create a culture where people in your organization are not afraid to report a medical error and know they or their colleagues will not be unjustly blamed. In one study, 49% of people said they would be ashamed if anyone knew they made a mistake, he said.

Encourage people to speak up when they see something wrong. In one study, only 54% of internists said they would would speak up if their supervisor told them to do something they knew was not right, compared to 97% of pilots, he said.

To test your staff, periodically say something wrong (such as that a meeting will be next Friday when it is scheduled for Thursday) and see if people question you.

Standardize care. There should be no variability in how staff treat patients from floor to floor or shift to shift. Patients with the same malady should receive the same treatment or patients are put at risk, he said. Teamwork and technology increase safety.

Create a reliable way to find the real causes of medical errors. There are tools available, such as those from the National Patient Safety Foundation. Its beefed-up root cause analysis, RCA2, can help organizations investigate errors.

“It’s only by understanding causes that you can fix things,” he said.

Prioritize your efforts. Focus first on errors that are most probable and most acute and therefore could hurt the most patients.