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I'm our Craven here, my upcoming
book, the mistakes that make us 

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in the book, I share insights 
and strategies for cultivating, 

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a culture of learning 
Improvement and Innovation a 

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place where mistakes are 
embraced as opportunities for 

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growth and punishment is 
recognized as counterproductive 

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to learn more about the mistakes
that make us, visit mistakes, 

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book.com. 
Hi, it's Mark Raven here. 

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Welcome back to lien blog. 
Audio is it's been a while, but 

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this is episode 325 for February
23rd. 20, 23 to 23 23, the 

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headline title of the post is 
Big mistakes or the result of 

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not learning from small 
mistakes. 

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This time in an operating room 
and you can find the blog post 

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at lean blog dot org, slash 
audio 325, so article caught my 

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eye today. 
It's a change of pace to think 

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about and write about mistakes, 
other than my own as I blogged 

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about. 
Out. 

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But didn't do an episode on. 
Wrote a blog post yesterday 

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about mistakes. 
I made with my mainly in 

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podcast, I made more mistakes 
today but hey, Healthcare 

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mistakes are more important. 
So the headline of the news 

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article is Penn Medicine 
Hospital cited over wrong site 

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surgery in. 
This is from Lancaster 

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Pennsylvania. 
So, Framing this in terms of 

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mistakes and I'm writing a new 
book trying to finish the 

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manuscript of a book about 
creating a culture of learning 

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from mistakes. 
You can learn more at mistakes. 

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Book.com by the way. 
Sorry for jamming, a plug in 

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there, and I'm talking about the
serious story. 

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So it's a mistake to perform 
surgery on the wrong leg. 

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It's not I've heard people use 
this phrase unintended mistake, 

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I mean that's redundant all 
mistakes are Intentional by 

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definition, intentional harm 
would be called sabotage or 

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assault. 
Not saying, that's what happened

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here seems like clearly a 
mistake. 

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So, from the article, it says, 
Pennsylvania health officials 

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have cited Lancaster. 
General Hospital for several 

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safety issues in recent months, 
including a wrong site. 

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Surgery pain, live reported 
February 23rd. 

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There was as the story says an 
anonymous complaint. 

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Matt seems like evidence would 
be Spected evidence of a parents

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or suspected lack of 
psychological safety this 

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anonymous complaint? 
I mean, why did it have to come 

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to that? 
Why can't people speak up? 

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About problems risks. 
Near-misses incidents harm. 

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So from the article, it says, 
state reports cited by the 

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publication show a surgical team
at the hospital performed 

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reconstruction surgery on a 
patient's wrong, ankle in 

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December. 
Clearly a mistake. 

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So what happened what we know 
from the article and I'm going 

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to Provide some educated guess 
conjecture here. 

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I guess the article does say a 
staff member marked the correct 

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ankle prior to surgery. 
That's good. 

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But did not place the mark 
within two inches of the 

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surgical site as per Hospital 
policy, that's bad maybe that's 

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a mistake but the starting to 
sound like to me a cultural 

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problem. 
Did people not feel safe to 

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speak up about this bad 
practice? 

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I mean we'd have to assume this 
wasn't the first time. 

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Somebody didn't Properly, Mark, 
the surgical site. 

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So then what happened? 
Another employee placed a 

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tourniquet on the wrong leg. 
And the surgical team realized 

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the error shortly after the 
operation. 

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So this mistake was a team 
effort and I'm not suggesting 

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that naming blaming, and 
shaming. 

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A group of people would be 
better than blaming just one 

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instead of asking who screwed up
not which person or people we 

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should ask, how can That have 
happened. 

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Prompted by a post by and 
Richardson on LinkedIn. 

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She's a nurse former nurse 
executive, patient, safety and 

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health care culture, advocate 
for lack of a more formal way of

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describing her. 
I wrote the following is a 

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response to her post. 
Some people when they read that 

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article while asked, who should 
be punished a better question is

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what could have prevented that 
maybe whose fault is it? 

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That the problem wasn't 
prevented unless that was the 

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first time that surgery had ever
been done, I'll propose 

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conjecture here. 
There's a high likelihood that 

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one or more of these things 
happened. 

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Previously won the surgeon 
didn't mark close enough to the 

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surgical site. 
We could call that a bad 

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practice to somebody almost put 
the tourniquet on the wrong leg.

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But Just in didn't do it, we 
might call that a near-miss, 

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they did it properly but they 
almost did it wrong. 

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And then third you maybe 
somebody did put the tourniquet 

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on the wrong leg but then caught
it and then put it on the 

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correct leg which would also be 
a near-miss even though the 

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patient wasn't harmed. 
So if people aren't speaking up 

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and Reporting bad practices and 
near misses and again I'm 

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assuming those have been 
happening, probably not a bad 

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assumption if they're not 
speaking. 

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That's a culture problem. 
So whose fault is that? 

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Not the Frontline staff, they 
don't create culture, look 

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higher in the org chart, don't 
blame the employees for not 

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speaking up, when they might 
feel like one or the following 

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are true one. 
When it's if they feel unsafe to

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speak up because they or 
somebody else will get in 

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trouble too, it's not worth the 
effort because nothing gets 

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fixed or three, they don't have 
time to report the problem. 

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And again, point to Maybe 
applies not worth the effort and

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again. 
So there's there's fear and 

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futility that's involved. 
So, if leaders aren't, actively 

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encouraging people to speak up 
about bad practices and 

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near-misses like really, really 
encouraging it on an ongoing 

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basis, that's a leadership 
problem. 

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If they're not rewarding the 
people who do speak up that's 

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the leadership problem and I 
don't mean giving them money. 

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I mean like treating them 
respectfully with you in a 

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reacting in a constructive way 
and thanking them for speaking 

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up. 
If they don't do that, it's a 

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leadership problem. 
If they marginalize or ignore or

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punish them, that's what 
leadership problem. 

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And if they're not turning 
incident reports that do happen 

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into effective problem solving 
which should lead to Improvement

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and prevention of future 
mistakes. 

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That's a culture problem. 
That's a leadership problem. 

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So for all of the loose talk 
that we hear about quote-unquote

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accountability, And I hate that 
word because it usually means 

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punishment. 
Why is it apparently only the 

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Frontline employees who ever 
face life-altering punishments. 

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Then I mean a 40,000 dollar fine
as was levied against the 

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hospital for this and other 
mistakes. 

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A 40,000 dollar find is not 
life-altering to the hospital or

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its leadership team. 
So a hospital, spokesperson made

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the predictable tired and 
seemingly inaccurate statement 

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like they always make quote, 
ensuring the safety of all 

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patients is our top priority end
of quote, as the late great, 

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Paul O'Neill might have asked 
how do we know that's really 

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true. 
How do we really know ensuring 

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the safety of all patients is 
our top priority every moment of

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every day. 
Is an ask in her LinkedIn post. 

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Why do these things still happen
in 2023 punishing mistakes or 

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threatening the punish them 
doesn't lead to fewer mistakes. 

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Some people believe it helps but
again punishing mistakes or 

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threatening to punish them 
doesn't lead to fewer mistakes. 

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It certainly doesn't get us to 
zero mistakes. 

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So what would be my evidence 
here? 

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If this was I'm not a lawyer, 
this is a court of law is my 

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closing argument. 
If punishing mistakes led to 

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fewer, mistakes that strategy 
would have worked by now. 

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But it hasn't. 
So it's time for a new approach.

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I mean, I'm not saying I have 
all the answers but my upcoming 

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book annoying plug here on the 
mistakes that make us explores 

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the idea of creating a culture 
of learning from mistakes. 

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It shares, what some 
organizations are doing to prove

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that a focus on learning and 
Improvement. 

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Instead of punishment is not 
actually just fair and just if 

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we want to use the language of 
just culture it's also more 

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effective. if we really, Make 
patient safety our top priority.

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And if we really want to reduce 
mistakes, we need to stop 

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punishing them. 
And instead start learning, 

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start improving, psychological 
safety. 

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Leads to physical safety. 
So now I'm just rambling after 

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reading the words in the post 
but again I hope maybe you'll go

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check it out. 
Lean blog dot org, slash audio 

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325. 
Make patient safety our top 

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priority. 
And if we really want to reduce 

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mistakes, we need to stop 
punishing them. 

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And instead start learning, 
start improving, psychological 

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safety. 
Leads to physical safety. 

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So now I'm just rambling after 
reading the words in the post 

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but again I hope maybe you'll go
check it out. 

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Lean blog dot org, slash audio 
325.