Tired doctor sitting alone in hallway

There are a lot of wise sayings about mistakes and how they make us better human beings but if they are so good for us, why do they feel so bad and why is it so hard to admit them at work? Most people will say they feel that that admitting an error is tantamount to professional suicide. However, when it comes to medical errors, healthcare experts are quickly discovering that talking about them can actually help to prevent them.

Let’s be clear, there are two and only two categories of mistakes in healthcare; clinical errors and everything else. Avoiding clinical errors is the Holy Grail of healthcare practice. Yet, even in that life-or-death situation the protocols designed to avoid clinical error can be improved by a culture that openly discusses them. When errors can be acknowledged, without fear of retribution, root causes can be unearthed, examined and corrected. Without that level of transparency, small details that lead to large errors remain buried and troublesome.

The Agency for Healthcare Research and Quality (AHRQ) recognized that the ability to call out mistakes could play a significant role in reducing medical errors and developed the TeamSTEPPS program, now implemented in all 50 U.S. states. The program pulled together research from high-risk environments like aviation and the military, and experts from high-stress situations like emergency departments and surgical suites. They found that medical errors can be reduced if everyone on the team feels comfortable speaking up to call out a mistake; even when it is about to be made by a leading physician or surgeon. When trust ranks over deference in the surgical suite, mistakes are avoided.

The ability to safely admit mistakes is just as important when working directly with patients. An innovative program at the University of Washington has found that most errors are systemic, and the result of team actions, rather than any individual provider. “We make errors as a team; we need to disclose errors as a team. It is a terrific way to learn how to work together effectively,” said Sarah Shannon, an associate professor in the University of Washington nursing school. “Errors raise the ante for the health-care team by bringing up reactions of guilt and blame, grief and anger among the team members, as well as between the team and the patient and family. We need to acquire the skills to communicate the error effectively.”

Admitting mistakes- safely

If nurturing great staff means giving them freedom to make mistakes, it can also mean exposing the organization to risk. Progressive companies are finding a way to counter that obstacle:

  • Communicate to employees that making a mistake once is OK, making the same mistake twice is not OK. Discuss the mistake with the direct manager and find ways to rectify the situation and its cause. Then work to make sure the mistake does not recur.
  • Make sure that employees admit and own their mistakes. A culture that supports safely admitting mistakes is not one that supports blaming others. Accountability is the only way an open culture can succeed.
  • Fix mistakes: Make sure a process is in place to fix the mistake, communicate it properly to others, document the fix and share progress on the “repair”.
  • Mistake guardrails: Establish policies, procedures and protocols to ensure the mistake doesn’t happen again. The team can do this together so that everyone is aware of the remedy, and it is communicated across the organization.

Internal surveys can give you a read on where your employee culture stands regarding errors. We can help you gain insight as to whether staff feels comfortable talking about them. Your healthcare system can’t address and prevent medical errors unless you know exactly when and how they are occurring. You can’t begin to change your culture unless you know what your employees are thinking.

When a patient has the opportunity to tell you how they feel about their care, they feel empowered, and acknowledged. This can increase patient satisfaction and as a result, your HCAHPS ROI. That closes the all important loop of clinical care, patient satisfaction and reimbursement. Find out more at HCXP, creator of a five point, 5 Star rating system for all in house satisfaction questionnaires and one comparison/benchmark reporting system.

CategoryGood Reads
  1. January 25, 2017

    All so true. I am working on a presentation abstract. Not failue to report errors, but failure to report potential risks — operational risk is the focus. I’m talking about apathetical organizations that don’t emphasize and encourage risk identification. Any thoughts on this?

  2. January 25, 2017

    Lee,failure to report risks and risk identification is the result of reactive practice as apposed to proactive preventative practice.The medical model of care is so behind in its thinking and practices on this. Lack of anticipatory skills and training which could be addressed through the adoption of a Proactive Human Factors Approach to care and safety of both patients and care staff.,

  3. January 25, 2017

    Thank you for your article. I think the most important work we can do in healthcare today

  4. January 25, 2017

    Healthcare is long overdue in adopting practices and principles from aviation and the military. As a TeamSTEPPS Master Trainer, I understand the importance of getting this message out and daily use of the tools in practice. Great article!!!

  5. January 25, 2017

    I recently experienced this and all those hindrances flashed before me, fear was the head of the race at the instant of occurrence . Yet, a knowing and Culture within our facility surged through my fear with Respect, myself, Accountability to others, those whom all were affected, and finally Responsibility gave way , especially when the accessibilitycto report errors are accessible in such a way, it gives one ability to reflect honestly on their part and responsibility to themselves,,the patient, and the facility. The end approach does bring about a unified outcome that promotes teamwork and the truest purpose of patient care!

  6. January 25, 2017

    Healthcare’s unwillingness to “bother” their physicians, nurses, and other providers, with potential risks and risk assessments is an invitation to committing avoidable errors. We can’t prevent what we refuse to define.

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