Acknowledging Our Mistakes
Some of the most brilliant minds and the most successful businesspeople in history have long stood behind the adage that mistakes can lead to greatnessif those who make the mistakes actually learn from them. In the litigious world we live in, it has become de rigueur to never admit we are at fault for anything. In the health care environment where lives are at stake, this philosophy may be even more prevalent. Admitting an error can not only expose a medical professional to the possibility of legal action, but it may also put licenses and jobs at risk. Realizing that crucial maintenance steps have been overlooked or ignored, or have not been done correctly, also warrant concern. Granted, there are times when legal action is entirely justified, but, if overall fear dominates our inability to face up to our mistakes, how then do we learn from them and rectify them?
In a recent issue of Weekly Jolt, our new e-newsletter, a story was published that one reader felt could pave the way to legal action. Concerned, I sought the advice of experts in the field. In one response to my question, 24×7 board member David Harrington, PhD, said that he is of the school of thought that would, simply publish the mistakes so all can learn, adding, if you hide them from others, no one learns.
Although the cost of learning may come high, I think it is safe to say that errors in health care are not intentional. Therefore, the true purpose of bringing errors to light is that others can benefit from them so that they can be avoided in the future. In addition, old ways that no longer serve a purpose can be challenged and revised.
With the rapid advances in tech-nology, there may exist numerous procedures that are outdated. On a weekly, if not daily, basis I receive press releases touting the latest and first-of-its-kind medical devices. With different techniques and equipment comes the need for new standards, but how can an industry keep pace with these swift changes?
Sadly, it often takes a tragedy for procedural changes to take effect, and I dont know that pulling mistakes out from under a bushel for all to see will happen anytime soon. What I do hope is that, under a bushel or not, when human or device errors do happen, we can move beyond simply blaming someone for the mistakes and focus on finding out why they occurred and how they can be prevented in the future.