“We’re writing about mistakes again, Curmudge? I thought that our discussions on April 1 and April 8 wrapped up this topic for good.”
“It’s got to stay on our radar screen, Jaded Julie. Those of us in health care require periodic reinforcement that the proper response to an error is not name, blame, and shame. So here’s a reminder, coming at you.”
“I seems so natural to blame someone who commits an error, and then we compound their embarrassment by calling them stupid. It’s as if that attitude is hardwired in everyone at birth. And then the blamed person feels so badly that they will do everything possible to hide any error that they make in the future. But none of this is new information. My guess is that your wanderings on the Web yielded some new insights about errors that you’d like to share with our readers.”
“You’re right, Julie. They are in a book by Kathryn Schulz called, Being Wrong: Adventures in the Margin of Error. She feels that we make errors because, as humans, we are capable of using a guessing strategy known as inductive reasoning. We make decisions based on what we think will happen in the future, i.e., by inductive reasoning, and some of our guesses regarding the future are wrong.”
“I think I understand, Curmudge. Humans have always used inductive reasoning to guide their trial-and-error development of tools, and in the modern age, their professional talents. If we couldn’t do that, we’d still be living in caves, or maybe in trees. So now, people like concert musicians—after extensive training and hours of practice—can play thousands of notes with few if any errors. But mistakes can and do occur because the performer is human. Hey, this sounds a lot like necessary fallibility that we talked about way back on February 19, 2009.”
“Although several kinds of mistakes can occur in health care, such as shortcuts that have gone awry, let’s focus on those that are purely unintentional. To quote Kathryn Schulz, ‘Embracing our fallibility is the only way to build effective backup systems to prevent or mitigate mistakes.’ ‘Understanding the origins of our mistakes is the only way we can learn to deal with them.’ And so we must ferret out and defuse the booby traps in our systems. Our search for the systemic root cause begins when a mistake or a near miss has been reported. We treasure near misses because they reveal potential problems without anyone’s having been harmed.”
“I suspect that near misses are more like buried treasure because they are so often hidden and not reported. So what’s the bottom line, Curmudge, as if I can’t already guess?”
“You know it as well as your own name, Jaded Julie. Get rid of the old name, blame, and shame culture and replace it with a just culture. That will allow us to find and replace those potentially error-causing aspects of our systems with checklists, standardized work, or decision-support software.”
Affinity’s Kaizen Curmudgeon
Another excellent article on patient safety: The Wrong Stuff: What it Means to Make Mistakes. http://www.slate.com/blogs/blogs/thewrongstuff/archive/2010/06/28/risky-business-james-bagian-nasa-astronaut-turned-patient-safety-expert-on-being-wrong.aspx
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About Me
Kaizen is a Japanese word meaning change for the better. A curmudgeon is a crusty, irascible, cantankerous old person. The Kaizen Curmudgeon blog consists principally of conversations between the Curmudgeon and Jaded Julie. Their topic is Lean (the Toyota Production System) and its applications in health care. We attempt to depict Curmudgeon as the resident Old Guy who possesses some degree of perspicacity and is not nearly as grouchy as the formal definition of curmudgeon suggests. As her name implies, Jaded Julie is a nurse who has “had it up to here” with waste and inefficiency. She is unsophisticated, somewhat feisty, and does not appreciate having to learn the Japanese terminology of Lean. Of course, both the Kaizen Curmudgeon and Jaded Julie are fictional. The author of Kaizen Curmudgeon is a retired Associate Professor of Chemistry who has been a volunteer in health care since 2004.
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