Sharing Stories vs. Placing Blame

Today we are settling into a rhythm and telling more stories. There are short and long stories, educational stories and moving stories. One in particular saddened and angered me in a way that I know I will carry forward with me through my journey in healthcare for the better.

Stories of patient safety are not just being told here, but at hospitals nationwide. Executives at hospitals send out “Good Catch Monday” e-mails broadcasting news of staff who prevented a medical error. Employees are surprised by hospital leaders and rewarded for utilizing “Stop the Line” regardless of whether an error was imminent or not.

As humans we will always want to rationalize and find a concrete answer upon which we can place our finger. Unfortunately in healthcare this translates to placing blame on a single individual when a medical error is involved. It was the nurse’s fault, he didn’t read the glucometer correctly. How could she be so unthinking as to place the baby in the wrong bassinet?  These thoughts are our tendencies.

But when we approach these questions from a systems standpoint, we can often find that our system design invites us to make an error.

Enter human-factors engineering.

This term is new to me, but I already see that it has its place in quality improvement. By blending what we know about human psychology with engineering, we can devise creative solutions in ergonomics and technology that can benefit healthcare professionals and reduce error.

The labeling system for the bassinets did not allow for cross checking of the arm band on the infant. The caution message on the glucometer covered up the qualitative reading, skewing what nurses were reading. Not who, but WHY?

Let’s think about the way in which our designs can hinder a person’s job rather than reactively displacing anger on someone. The latter results in a job loss and poor event memory.  The former promotes discussion and opportunity for improvement that is passed on in those Monday morning e-mails.

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