Dangers of a Pithy Quote About Patient Safety?
Yesterday, I tweeted a quote about patient safety that I've seen posted on the wall or bulletin board in many hospitals:
“To err is human, to cover up is unforgivable, and to fail to learn is inexcusable.”
Could this quote be possibly misinterpreted?
Sir Liam Donaldson is the Chief Medical Officer of England.
In my reading of the Donaldson quote, I agreed that it's indeed human to make mistakes and errors. We're not robots or computers – we forget things and we get sloppy at times. That's why we have to design systems that prevent good people from making errors (as Dr. Atul Gawande writes about in his excellent books).
Toyota's philosophy, called “respect for people” recognizes this human frailty through the practice of “poka yoke” or mistake proofing. Toyota's approach was originally called “respect for humanity,” which as I've heard it explained, includes the idea that we have to respect our human nature that people aren't perfect and we can't have a workplace that expects them to be other than human.
In the healthcare realm, or any workplace, covering up errors and near misses means that we're doomed to repeat the same errors – causing more quality problems and harm to patients. To solve problems and proactively improve future safety problems, we have to be open and non-blaming in our behavior when people raise an issue or a risk. We have to be “hard on the process, soft on the people,” as my friend Pascal Dennis says.
If covering up problems leads to more harm, then that certainly could be considered unforgivable. Making one error, an honest human mistake, isn't as bad as making a conscious choice to cover up that problem (there's a different level of awareness involved).
Benjamin wondered if the quote could have the effect of “browbeating” people. He raises an excellent point. In a traditional organizational culture, a “blame and shame” culture, people aren't going to be open and honest about risks and errors and near misses. It's well studied and shown that hospitals and their people underreport errors — arguably due to a culture of fear – shame and blame.
I think Benjamin and I would agree that we have to do more than just lecture and point fingers at people for not reporting problems. We can't just blame individuals for covering up problems — we have to work on the culture and management system that leads to that fear.
We have to ask “why do people cover up problems?” Everybody works as part of a system. We can hope some people will be heroic, risking punishment or their jobs. But not everybody can or will take that risk. If people cover up problems, that's a deep management and culture issue, not an individual issue.
That quote, if hung on the wall in the wrong organization or if hung on the wall without leadership, could shame people into not coming forward — I think Benjamin is right on that and I appreciate him for moving the discussion forward. Who says Twitter is worthless?
Looking to the last part of the quote: To fail to learn how to improve our management system is indeed inexcusable.