Punishment Promotes Problems

Resonating with me today was the point made that by punishing mistakes, the medical industry struggles to make progress in preventing future errors. 

Hospitals have reporting systems that make it possible for residents and other medical professionals to report unsafe conditions or make suggestions for improvements in hospital policies and procedures. This is an integral part of understanding what issues exist and how to address them in such a way that makes the hospital a safer place to be.

One issue with reporting systems is that they are often not anonymous, for the purpose of being able to contact those who were involved in the particular incident so that they can describe their particular experience. Since individuals have to identify themselves, there is fear of retaliation, and there is fear that those who are reported in the event will become defensive. This dissuades  people who experience adverse events from reporting and therefore many important events typically fly under the radar, and innumerable opportunities for improvement are missed.

I had an experience with the hospital reporting system that highlights this issue. I was caring for a patient with an ejection fraction of <20%. The patient had recovered from his illness requiring IMC level of care and he was sent down to the floors. He needed a simple inpatient surgery the next day. I had inadvertently learned that his surgery was delayed because he had gone into heart failure and had since ended up in the ICU. When I reviewed his chart to find out why a stable patient had so quickly decompensated, it appeared that a routine surgical order set had been placed in the chart and the patient had been put on 125 cc/hr of maintenance IVF overnight despite his low ejection fraction. He eventually went into respiratory distress, a rapid response was called and the patient was subsequently intubated for acute hypoxic respiratory failure, pulmonary edema all likely secondary to acute decompensated heart failure.

In reviewing this case, I felt as though it was irresponsible for the order set to include maintenance IVF without any reminder to review the cardiac history. I felt as though there was a window for improvement, and that the order set should be reviewed so that this wouldn’t happen to patients in the future.

I filled out an event report explaining the situation, and immediately received lash back from the surgery department, they stated they did not know what I was talking about, that they did not place the order and that they were not the primary team for the patient. The case was closed soon after.

Although some other good came out of the event reporting – (the hospitalist that was caring for that particular patient that day had reported that she had a census close to 30 and so she did not have the time to notice the impending respiratory failure, and thus the hospital hired more hospitalists in response), I was surprised by the lack of accountability and the defensiveness of the surgical department despite the fact that my report had not put blame on any individual and was instead a suggestion to review the order set systems that are commonly used in the hospital.

I can personally admit to being more fearful of reporting than I was prior to this event because of the lash back that I experienced. I was afraid of running into the surgeons around the hospital and being questioned. I was afraid of being blamed for “getting others in trouble.” That was the way they reacted in their response through the reporting system. Although I still send in reports for important safety events that I experience, my fear is that others will not, that the fear of retaliation is too great to overcome. In the end, this is infinitely harmful to not only the hospital, but the patients whose lives and well being depend on our commitment to safety.

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