I'm our Craven here, my upcoming book, the mistakes that make us
in the book, I share insights and strategies for cultivating,
a culture of learning Improvement and Innovation a
place where mistakes are embraced as opportunities for
growth and punishment is recognized as counterproductive
to learn more about the mistakes that make us, visit mistakes,
book.com. Hi, it's Mark Raven here.
Welcome back to lien blog. Audio is it's been a while, but
this is episode 325 for February 23rd. 20, 23 to 23 23, the
headline title of the post is Big mistakes or the result of
not learning from small mistakes.
This time in an operating room and you can find the blog post
at lean blog dot org, slash audio 325, so article caught my
eye today. It's a change of pace to think
about and write about mistakes, other than my own as I blogged
about. Out.
But didn't do an episode on. Wrote a blog post yesterday
about mistakes. I made with my mainly in
podcast, I made more mistakes today but hey, Healthcare
mistakes are more important. So the headline of the news
article is Penn Medicine Hospital cited over wrong site
surgery in. This is from Lancaster
Pennsylvania. So, Framing this in terms of
mistakes and I'm writing a new book trying to finish the
manuscript of a book about creating a culture of learning
from mistakes. You can learn more at mistakes.
Book.com by the way. Sorry for jamming, a plug in
there, and I'm talking about the serious story.
So it's a mistake to perform surgery on the wrong leg.
It's not I've heard people use this phrase unintended mistake,
I mean that's redundant all mistakes are Intentional by
definition, intentional harm would be called sabotage or
assault. Not saying, that's what happened
here seems like clearly a mistake.
So, from the article, it says, Pennsylvania health officials
have cited Lancaster. General Hospital for several
safety issues in recent months, including a wrong site.
Surgery pain, live reported February 23rd.
There was as the story says an anonymous complaint.
Matt seems like evidence would be Spected evidence of a parents
or suspected lack of psychological safety this
anonymous complaint? I mean, why did it have to come
to that? Why can't people speak up?
About problems risks. Near-misses incidents harm.
So from the article, it says, state reports cited by the
publication show a surgical team at the hospital performed
reconstruction surgery on a patient's wrong, ankle in
December. Clearly a mistake.
So what happened what we know from the article and I'm going
to Provide some educated guess conjecture here.
I guess the article does say a staff member marked the correct
ankle prior to surgery. That's good.
But did not place the mark within two inches of the
surgical site as per Hospital policy, that's bad maybe that's
a mistake but the starting to sound like to me a cultural
problem. Did people not feel safe to
speak up about this bad practice?
I mean we'd have to assume this wasn't the first time.
Somebody didn't Properly, Mark, the surgical site.
So then what happened? Another employee placed a
tourniquet on the wrong leg. And the surgical team realized
the error shortly after the operation.
So this mistake was a team effort and I'm not suggesting
that naming blaming, and shaming.
A group of people would be better than blaming just one
instead of asking who screwed up not which person or people we
should ask, how can That have happened.
Prompted by a post by and Richardson on LinkedIn.
She's a nurse former nurse executive, patient, safety and
health care culture, advocate for lack of a more formal way of
describing her. I wrote the following is a
response to her post. Some people when they read that
article while asked, who should be punished a better question is
what could have prevented that maybe whose fault is it?
That the problem wasn't prevented unless that was the
first time that surgery had ever been done, I'll propose
conjecture here. There's a high likelihood that
one or more of these things happened.
Previously won the surgeon didn't mark close enough to the
surgical site. We could call that a bad
practice to somebody almost put the tourniquet on the wrong leg.
But Just in didn't do it, we might call that a near-miss,
they did it properly but they almost did it wrong.
And then third you maybe somebody did put the tourniquet
on the wrong leg but then caught it and then put it on the
correct leg which would also be a near-miss even though the
patient wasn't harmed. So if people aren't speaking up
and Reporting bad practices and near misses and again I'm
assuming those have been happening, probably not a bad
assumption if they're not speaking.
That's a culture problem. So whose fault is that?
Not the Frontline staff, they don't create culture, look
higher in the org chart, don't blame the employees for not
speaking up, when they might feel like one or the following
are true one. When it's if they feel unsafe to
speak up because they or somebody else will get in
trouble too, it's not worth the effort because nothing gets
fixed or three, they don't have time to report the problem.
And again, point to Maybe applies not worth the effort and
again. So there's there's fear and
futility that's involved. So, if leaders aren't, actively
encouraging people to speak up about bad practices and
near-misses like really, really encouraging it on an ongoing
basis, that's a leadership problem.
If they're not rewarding the people who do speak up that's
the leadership problem and I don't mean giving them money.
I mean like treating them respectfully with you in a
reacting in a constructive way and thanking them for speaking
up. If they don't do that, it's a
leadership problem. If they marginalize or ignore or
punish them, that's what leadership problem.
And if they're not turning incident reports that do happen
into effective problem solving which should lead to Improvement
and prevention of future mistakes.
That's a culture problem. That's a leadership problem.
So for all of the loose talk that we hear about quote-unquote
accountability, And I hate that word because it usually means
punishment. Why is it apparently only the
Frontline employees who ever face life-altering punishments.
Then I mean a 40,000 dollar fine as was levied against the
hospital for this and other mistakes.
A 40,000 dollar find is not life-altering to the hospital or
its leadership team. So a hospital, spokesperson made
the predictable tired and seemingly inaccurate statement
like they always make quote, ensuring the safety of all
patients is our top priority end of quote, as the late great,
Paul O'Neill might have asked how do we know that's really
true. How do we really know ensuring
the safety of all patients is our top priority every moment of
every day. Is an ask in her LinkedIn post.
Why do these things still happen in 2023 punishing mistakes or
threatening the punish them doesn't lead to fewer mistakes.
Some people believe it helps but again punishing mistakes or
threatening to punish them doesn't lead to fewer mistakes.
It certainly doesn't get us to zero mistakes.
So what would be my evidence here?
If this was I'm not a lawyer, this is a court of law is my
closing argument. If punishing mistakes led to
fewer, mistakes that strategy would have worked by now.
But it hasn't. So it's time for a new approach.
I mean, I'm not saying I have all the answers but my upcoming
book annoying plug here on the mistakes that make us explores
the idea of creating a culture of learning from mistakes.
It shares, what some organizations are doing to prove
that a focus on learning and Improvement.
Instead of punishment is not actually just fair and just if
we want to use the language of just culture it's also more
effective. if we really, Make patient safety our top priority.
And if we really want to reduce mistakes, we need to stop
punishing them. And instead start learning,
start improving, psychological safety.
Leads to physical safety. So now I'm just rambling after
reading the words in the post but again I hope maybe you'll go
check it out. Lean blog dot org, slash audio
325. Make patient safety our top
priority. And if we really want to reduce
mistakes, we need to stop punishing them.
And instead start learning, start improving, psychological
safety. Leads to physical safety.
So now I'm just rambling after reading the words in the post
but again I hope maybe you'll go check it out.
Lean blog dot org, slash audio 325.