Ending a culture of blame Creating safer health care

One of the first representation cases I was involved in when I became a union president concerned the death of a patient who had received the wrong type of blood. The nurse caring for the patient was a highly experienced, extremely competent intensive care nurse. She had given hundreds of units of blood without incident in her career, yet on one fateful night she administered the wrong blood and the patient ended up developing a severe reaction and later died.

Eventually it was determined that the patient's death was not related to the transfusion error, but the seriousness of the mistake was still a major issue. Some administrators called for the nurse to be immediately fired. Their view was, get rid of the nurse and the problem would be gone. Fortunately an enlightened hospital CEO recognized the error was related more to flawed policies and procedures than to an incompetent nurse. By focusing on the system instead of blaming the individual, the hospital made its entire blood delivery system safer for hundreds of patients and a competent, experienced nurse was able to continue to provide excellent care.

As the years went by, I learned that my early experience was more the exception than the rule. When errors occurred, it seemed everyone spent more time looking for someone to blame than looking at the system faults. As a result of the blame game, a culture of silence developed in the health care system.

A new report from the Institute of Medicine reaffirms what health professionals have long known, that medical errors are a major part of our medical system and that the vast majority of errors are not related to incompetent practitioners but rather to flawed systems. To focus on blaming individuals might cure a fraction of the errors. But to eliminate the rest of the errors and save thousands of lives, the focus must be on the system in which errors occur.

It took a series of fatal crashes before the airline industry reached the conclusion that it could save more lives by fixing system problems than by affixing blame to individuals. It took the disaster at Three Mile Island to bring the nuclear power industry to this same conclusion.

Today, medical errors kill thousands more than any plane crash or nuclear accident. It is long past time for the federal government to establish an oversight system such as that in the airline industry. Until this happens, enlightened health care administrators should immediately adopt the recommendation that calls for reporting of errors coupled with protection of those individuals who voluntarily report. Let's start today to create a truly safe health care system before more patients die from preventable errors.