Suicide After Medical Error Highlights Importance of Support for Clinicians
"We operate from a belief that no one intends for errors to happen or seeks to create errors," says Edmonson. "Instead we realize it is often a complex interaction between the culture, the systems, the processes, and the people in an organization. We respond by thanking the person who reported the error, seeking to comfort those involved, seeking the truth of the situation, rebuilding trust among the team, and finding solutions, both people and process based, to mitigate further risk."
THPHD draws a distinction between human error, at risk behaviors, and reckless behaviors when examining what went wrong and the reasons behind it. Edmonson says errors and all variances should be systematically addressed through just culture algorithms for consistency, completeness, categorizing, and actions to be taken post analysis.
"One of the most difficult tenets of a true just culture is to not focus on the outcome of the behavior, but rather seek to understand the personal decisions, system influence, and context in which the decision was made, which helps us to address the real issues," he says. "It is very possible that two people can commit the same error with very different outcomes, so we have to ask ourselves from a just culture perspective, is one more egregious than the other because of the outcome?"
In light of the Seattle story, this is a pertinent question to ask.
"Removing the outcome bias, the fear of reporting, and having leaders that clearly understand how to operate in the just culture and to support staff is the best path to a reporting of errors," adds Edmonson.
Rebecca Hendren is a senior managing editor at HCPro, Inc. in Danvers, MA. She edits www.StrategiesForNurseManagers.com and manages The Leaders' Lounge blog for nurse managers. Email her at firstname.lastname@example.org.
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