Improving patient safety requires a commitment to transparency

An excerpt from Goal Play!: Leadership Lessons from the Soccer Field.

I recently had lunch with one of my soccer alumnae, now aged 28. Tovah said to me, “Do you remember that play I made in the tournament we went to in Connecticut? I mean when I mistakenly headed the ball into our own goal and caused us to lose the game.”

“Well, I was devastated and was sitting on the grass after the game, sobbing my heart out. You came over and said, ‘Don’t worry, Tovah, great defenders sometimes score against themselves. Only the best defenders go out aggressively after every open ball. Every now and then, it deflects and goes into the net. You did a wonderful job.’ I stopped crying, stood up, brushed myself off, and walked away smiling, saying to myself, ‘I’m a great defender!’ That season was very meaningful to me.”

She remembered this 14 years later.

You never know when a kind or supportive word from you will make a lasting difference. Whether you intend to be or not, you are a role model and your opinion counts. When you offer solace or encouragement to someone who has made a mistake, it can make a difference. To do so, though, you must truly believe that it is not the mistake that matters, but the lesson that can be drawn from it.

But let’s take this idea even further: As a leader, you must do everything you can to encourage people to admit mistakes they have made and to call out problems they have found in the organization. If people think they will get in trouble for having erred, or for having brought up a systemic problem in the organization, those errors and problems will go unreported. The person and the organization will thereby lose an opportunity to grow and improve. Accordingly, a strong commitment not only to transparency but to a just culture is essential to achieve continuous improvement.

You can see this philosophy in action through an event that happened at Beth Israel Deaconess Medical Center in July of 2008. A patient woke up after orthopaedic surgery and asked her doctor, “Why is the bandage on my right ankle instead of my left ankle?” It was at that moment that the surgeon realized he had operated on the wrong limb. It is impossible to know who was more distraught, the patient or the doctor who realized that he had violated a life-long oath to “do no harm.”

The surgeon immediately notified his chief of service and me, the CEO. After all of our department chiefs and quality assurance staff met to review the underlying causes of the error, we unanimously decided to publicize the case broadly throughout the hospital. We did so out of the belief that there were lessons to be learned about pre-operative procedures, which would affect the hundreds of doctors, nurses, surgery technicians, and residents engaged in surgeries at our hospital. I also published the story on my blog in the hope that our experience might be of value to workers in other hospitals.

It was quite clear that the hospital’s “time-out” protocol, which was designed to avoid precisely this kind of error, had not been properly carried out. In the weeks following this disclosure, a number of people asked me if we intended to punish the surgeon in charge of the case, as well as others in the OR who had not adhered to that procedure. Some were surprised by my answer, which was, “No.”

I felt that those involved had been punished enough by the searing experience of the event. They were devastated by their error and by the realization that they had participated in an event that unnecessarily hurt a patient. Further, the surgeon immediately reported the error to his chief and to me and took all appropriate actions to disclose and apologize to the patient. He also participated openly and honestly in the case review.

My reaction was supported by one of our trustees, who likewise responded, “God has already taken care of the punishment.” He pointed out that it would be hard to imagine a punishment greater than the self-imposed distress that the surgeon already felt. He had taken a professional oath to do no harm, and here he had, in fact, done harm. But another trustee said that it just didn’t feel right that this highly trained physician, “who should have known better,” would not be punished. “Wouldn’t someone in another field be disciplined for an equivalent error?” he asked.

This was a healthy debate for us to have, but a wise comment by a colleague made me realize that I was over-emphasizing the wrong point (i.e., the doctor’s sense of regret) and not clearly enunciating the full reason for my conclusion. The head of our faculty practice put it better than I had, “If our goal is to reduce the likelihood of this kind of error in the future, the probability of achieving that is much greater if these staff members are not punished than if they are.”

I think he was exactly right, and I believe this is the heart of the logic shared by our chiefs of service during their review of the case. Punishment in this situation was more likely to contribute to a culture of hiding errors rather than admitting them. And it was only by nurturing a culture in which people freely disclose errors that the hospital as a whole could focus on the human and systemic determinants of those errors.