Medical Error

Patients trust medical providers for care during vulnerable periods of their lives – a trust that medical providers hold sacred. Perhaps this is why the rate of medical errors with adverse consequences is so unsettling. A recent study by the Lehman center, reported by the Boston Globe on 12/3/2014, found that nearly 25% of Massachusetts residents say that they, or someone close to them, have experienced a medical mistake in the last five years.
At first blush it may seem that the individual providers are to blame. A doctor makes an incorrect diagnosis. A pharmacist does not catch an adverse drug interaction. A nurse administers medication to the wrong patient. Although patients tend to see medical mistakes as isolated incidences pertaining to their doctor, hospitals and medical providers understand that most of the challenges are systemic. As cathartic as it may feel to find fault with someone, focusing on an individual impedes effective problem solving and leaves in place all of the organizational structures and processes underlying the mistake making it more likely that similar mistakes will happen again.

A better approach than individual blame, therefore, is to look at what we call contribution. That is, what are all of the decisions, actions and processes that happened or didn’t happen that played a part in the mistake? The shift in approach is not just semantic. When we focus on blame, people are less likely to fully disclose their part in what happened because they are afraid of the consequences. The goal is to find fault and then blame those who are wrong. When we look for contribution, we search for the root causes of a mistake and it is a group endeavor. The goal is to understand what happened – at the individual level, process level and organizational structure level. 

A contribution-based approach, therefore, uncovers the widest range of drivers which in turn leads to stronger problem solving and more buy in among staff for solutions. The approach also sets up future inquiries for success because people learn to trust that they won’t be targeted and left holding the bag.

One of the challenges we face reducing medical error cited by the Globe article is that we really don’t understand where we are. Reporting standards have changed. Data are heavily concentrated in narrow areas of care such as acute care. And many raise questions about under-reporting – both among patients and their providers. This is a complex problem with many moving parts and its solution is not easily boiled down to some template. But we’ll never get a handle on it until we fully understand the organizational, individual, cultural, and cognitive contributions – and that requires a community effort focused on understanding contribution.