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Safety Samplings | | SAFETY SAMPLINGS
IHI: Planning for a Clinical Crisis: Next Steps
“Have front line staff been invited to participate in the root cause analysis of the event” Does leadership recognize that inclusion promotes learning and healing, whereas exclusion promotes blame””
“The system approach acknowledges that human beings are fallible and that errors are to be expected. Errors are seen as consequences rather than causes, “having their origins not so much in the perversity of human nature as in upstream, systemic factors. Countermeasures include system defenses to prevent or recognize and correct error. When the adverse event occurs, the important issue is not who blundered, but why the defenses failed.” (Richard and Mary Catherine Karl quoting James Reason in Adverse Events: Root Causes and Latent Factors from Surg Clin N Am 92 (2012) 89-100 doi:10.1016/j.suc.2011.12.003 from p.91)
Medically Induced Trauma Support Services (MITSS) is an organization dedicated to helping those who have endured trauma related to medical errors. This is for patients as well as clinicians. The hotline is available on the website. There are also a lot of resources for organizations in setting up and evaluating your environment for how supportive you are to families and clinicians during and after adverse events on this page:http://www.mitss.org/healthcareorgs_home.html
Raising the Index of Suspicion
“A logical deference to expertise, meaning it is natural and often reasonable for people to defer final judgment to those who they perceive to be more "qualified." If the person voicing the concern was reluctant to pursue it, avoided or backed down from the conversation, or felt the provider was not listening, workplace intimidation may play a role. But this is not always the case. Instead, the issue may be that the person questioning the patient's care has been easily convinced that their concern is unfounded, and the person being questioned has not perceived the voiced concern as a possible, credible patient threat. Neither possesses a required element to safeguard patients: an appropriately high index of suspicion for errors. A low index of suspicion is particularly problematic in a healthcare system that already is reluctant to acknowledge human error or value the contributions from every person, regardless of rank, who interacts with the patient.”
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