“Blame and Punish” Doesn’t Work
There are two problems with the “blame and punish” approach. First, it is predicated on the belief that providers make errors because they are poorly trained, inept, or just plain careless. Sometimes this is the case.
However, the vast majority of peer reviews that I’ve participated in involved an error performed by extremely well trained, highly skilled clinicians with the highest level of integrity and vigilance. The real problem lies in the human condition.
Humans make mistakes. Always have, always will.
In college, I worked summers in a factory that applied coating to paper. This combined colossal machines spinning at breakneck speeds, huge rolls of paper, and hands—a recipe for handless employees. But accidents rarely happened. Over time, the mill engineers had designed systems so foolproof that the workers couldn’t chop their hands off, even if they wanted to. This level of safety was achieved, in principle, by learning how errors were made so that future errors could be prevented. It was not achieved by blaming handless employees. This paper-plant process recognizes the fallible nature of human beings; it’s the same recognition we need in medicine.
Whether we commit a systems error (e.g., the lab test results arrived after the patient was discharged), a cognitive error (e.g., I continue to believe this pulmonary embolism is pneumonia because my night-coverage partner signed it out as pneumonia), or simply a human error (e.g., the lab forgot to call a critical result to the ordering physician), we work in systems that often result in errors. And the only meaningful hope we have to reduce errors depends on our ability to identify them and build systems so safe that we couldn’t hurt a patient, even if we tried.
This leads to the second problem with the blame-and-punish mentality: It breeds concealment of errors, as providers become reticent to expose mistakes for fear of retribution. Thus, an important pipeline of information about system deficiencies dries up, and we are left to suffer the same cycle of errors.
Budging the quality and patient-safety needle will require a culture that freely and openly admits mistakes in order to analyze and prevent future mistakes. This is inherently difficult for most of us to do, and next to impossible when we fear reprimand. Then again, if we endeavor to fundamentally enhance the safety of hospital care, we must allow providers to openly discuss errors without fear of rebuke. Accomplishing this will require understanding, leadership and action—and it starts with each of us.
Anything short of this will just result in more bad pages. TH
Dr. Glasheen is associate professor of medicine at the University of Colorado Denver, where he serves as director of Hospital Medicine and the Hospitalist Training Program, and as associate program director of the Internal Medicine Residency Program.