Skip to content
  • About
  • Contact
  • Contribute
  • Book
  • Careers
  • Podcast
  • Recommended
  • Speaking
  • All
  • Physician
  • Practice
  • Policy
  • Finance
  • Conditions
  • .edu
  • Patient
  • Meds
  • Tech
  • Social
  • Video
    • All
    • Physician
    • Practice
    • Policy
    • Finance
    • Conditions
    • .edu
    • Patient
    • Meds
    • Tech
    • Social
    • Video
    • About
    • Contact
    • Contribute
    • Book
    • Careers
    • Podcast
    • Recommended
    • Speaking

Why it is critical we learn from past health care mistakes

Joshua Tepper, MD and Danielle Martin, MD
Physician
April 15, 2015
Share
Tweet
Share

Forty is the new thirty. Orange is the new black. And failure is the new success.

It seems these days that no success story is complete without a failure (or two) along the way: the bankruptcy that gave birth to a successful company; the entrepreneur who lost it all just before hitting the Fortune 500. Entire issues of the Harvard Business Review and the New York Times Magazine have been devoted to failure. In the business world, leaders are often told: “Fail fast, fail early, fail often.”

In many sectors it is understood that to innovate, we must accept — even celebrate — failure.

Health care needs positive innovation. At nearly 12 percent of our GDP, health care is a huge part of the Canadian economy, and one in which new ways of doing business are needed — yet it is an industry that has not accepted that part of improvement must be a willingness to fail.

Thus when we fail in health care, we often double-fail: once in the event and again when we are unable to recognize, name and learn from that failure.

In health care, where lives are on the line, failing early and often understandably sounds unpalatable. But of course we do fail in health care. And while we don’t want to encourage failure, we do need to shift away from a culture that can’t acknowledge failure towards one where it is understood to be part of the process of improvement.

Failures in health care occur at two levels: the level of the individual patient and the system level. It is often easy to recognize failures at the patient level. These are when medications get mixed up, unnecessary infections occur, or poor communication leads to harm. We are getting better at communicating failure at the provider-patient level. Organizations are adopting policies and approaches that facilitate sharing — moving away from “blame-and-shame” cultures in order to improve.

However, learning within a single organization is not enough when there are thousands of organizations that make up our health system. Right now, we have limited means to facilitate learning from each others’ failures across organizations. This is particularly worrisome in an industry where similar environments and sets of interactions repeat themselves. An ambiguously labeled vial that leads to medication error in one long-term  care home will be identical to vials in hundreds of other homes. A cleaning process susceptible to human error used in one operating room will be used in dozens of other operating rooms the same day.

System level failures in health care happen but are harder to see.

In a public health care system, too often system failures end up as fodder for Question Period battles rather than impetus for learning. When investments have been made in new models of health service funding and delivery that don’t work out, it can be difficult to proclaim failure as a means to move toward success. But in the absence of a willingness to be open about policy ideas that didn’t pan out, we risk continuing to invest in sub-par models of care delivery and we hinder our ability to achieve excellence as a system.

Patients and the public are part of the answer.

We all put tremendous faith in the health care system at times of incredible vulnerability. Patients and families want to trust in our system; they need to believe that when the stakes are so high, it will work. But providers and organizations also need to trust patients and the public that they will not only understand our failings but help us do better.

The best way to honor a person who has been harmed by a health care failure is to do everything possible to learn from that failure so that it will not be repeated.

ADVERTISEMENT

Solutions are not easy. Some can be learned from other industries, some will be health care specific. We need structures and processes so learning can occur across the system. We need the health education system to prepare providers for a career learning from, and not burying, failure.

Failures must become teachable moments, not professional risks.

In an industry as large and complex as health care, where innovation is a must, we are bound to make errors. But it’s the double-failure that we should worry about: the inability to name and learn from our failures so that we can do better.

Joshua Tepper and Danielle Martin are family physicians in Canada. They are both expert advisors, Evidence Network.

Prev

Is it time to abandon the 9 to 5 workweek in hospitals?

April 15, 2015 Kevin 19
…
Next

We have already changed the way we think about cancer

April 15, 2015 Kevin 1
…

Tagged as: Primary Care

Post navigation

< Previous Post
Is it time to abandon the 9 to 5 workweek in hospitals?
Next Post >
We have already changed the way we think about cancer

ADVERTISEMENT

More in Physician

  • Why billionaires dress like college students

    Osmund Agbo, MD
  • Reclaiming physician agency in a broken system

    Christie Mulholland, MD
  • What burnout does to your executive function

    Seleipiri Akobo, MD, MPH, MBA
  • Dealing with physician negative feedback

    Jessie Mahoney, MD
  • Why CPT coding ambiguity harms doctors

    Muhamad Aly Rifai, MD
  • Moral injury, toxic shame, and the new DSM Z code

    Brian Lynch, MD
  • Most Popular

  • Past Week

    • Rebuilding the backbone of health care [PODCAST]

      The Podcast by KevinMD | Podcast
    • The flaw in the ACA’s physician ownership ban

      Luis Tumialán, MD | Policy
    • Why you should get your Lp(a) tested

      Monzur Morshed, MD and Kaysan Morshed | Conditions
    • The paradox of primary care and value-based reform

      Troyen A. Brennan, MD, MPH | Policy
    • Why CPT coding ambiguity harms doctors

      Muhamad Aly Rifai, MD | Physician
    • Escaping the trap of false urgency [PODCAST]

      The Podcast by KevinMD | Podcast
  • Past 6 Months

    • Rebuilding the backbone of health care [PODCAST]

      The Podcast by KevinMD | Podcast
    • The dangerous racial bias in dermatology AI

      Alex Siauw | Tech
    • When language barriers become a medical emergency

      Monzur Morshed, MD and Kaysan Morshed | Physician
    • The dismantling of public health infrastructure

      Ronald L. Lindsay, MD | Physician
    • The flaw in the ACA’s physician ownership ban

      Luis Tumialán, MD | Policy
    • A neurosurgeon’s fight with the state medical board [PODCAST]

      The Podcast by KevinMD | Podcast
  • Recent Posts

    • Why clinicians must lead the health care tech revolution [PODCAST]

      The Podcast by KevinMD | Podcast
    • Advance directives not honored: a wife’s story

      Susan Hatch | Conditions
    • Why billionaires dress like college students

      Osmund Agbo, MD | Physician
    • The therapy memory recall crisis

      Ronke Lawal | Conditions
    • A urologist explains premature ejaculation

      Martina Ambardjieva, MD, PhD | Conditions
    • Why medical organizations must end their silence

      Marilyn Uzdavines, JD & Vijay Rajput, MD | Policy

Subscribe to KevinMD and never miss a story!

Get free updates delivered free to your inbox.


Find jobs at
Careers by KevinMD.com

Search thousands of physician, PA, NP, and CRNA jobs now.

Learn more

View 1 Comments >

Founded in 2004 by Kevin Pho, MD, KevinMD.com is the web’s leading platform where physicians, advanced practitioners, nurses, medical students, and patients share their insight and tell their stories.

Social

  • Like on Facebook
  • Follow on Twitter
  • Connect on Linkedin
  • Subscribe on Youtube
  • Instagram

ADVERTISEMENT

ADVERTISEMENT

  • Most Popular

  • Past Week

    • Rebuilding the backbone of health care [PODCAST]

      The Podcast by KevinMD | Podcast
    • The flaw in the ACA’s physician ownership ban

      Luis Tumialán, MD | Policy
    • Why you should get your Lp(a) tested

      Monzur Morshed, MD and Kaysan Morshed | Conditions
    • The paradox of primary care and value-based reform

      Troyen A. Brennan, MD, MPH | Policy
    • Why CPT coding ambiguity harms doctors

      Muhamad Aly Rifai, MD | Physician
    • Escaping the trap of false urgency [PODCAST]

      The Podcast by KevinMD | Podcast
  • Past 6 Months

    • Rebuilding the backbone of health care [PODCAST]

      The Podcast by KevinMD | Podcast
    • The dangerous racial bias in dermatology AI

      Alex Siauw | Tech
    • When language barriers become a medical emergency

      Monzur Morshed, MD and Kaysan Morshed | Physician
    • The dismantling of public health infrastructure

      Ronald L. Lindsay, MD | Physician
    • The flaw in the ACA’s physician ownership ban

      Luis Tumialán, MD | Policy
    • A neurosurgeon’s fight with the state medical board [PODCAST]

      The Podcast by KevinMD | Podcast
  • Recent Posts

    • Why clinicians must lead the health care tech revolution [PODCAST]

      The Podcast by KevinMD | Podcast
    • Advance directives not honored: a wife’s story

      Susan Hatch | Conditions
    • Why billionaires dress like college students

      Osmund Agbo, MD | Physician
    • The therapy memory recall crisis

      Ronke Lawal | Conditions
    • A urologist explains premature ejaculation

      Martina Ambardjieva, MD, PhD | Conditions
    • Why medical organizations must end their silence

      Marilyn Uzdavines, JD & Vijay Rajput, MD | Policy

MedPage Today Professional

An Everyday Health Property Medpage Today
  • Terms of Use | Disclaimer
  • Privacy Policy
  • DMCA Policy
All Content © KevinMD, LLC
Site by Outthink Group

Why it is critical we learn from past health care mistakes
1 comments

Comments are moderated before they are published. Please read the comment policy.

Loading Comments...