The Aftermath of Errors

Hello All,

Happy Friday! I hope your team won in last week’s Super Bowl! I always hope for an exciting game, and this game certainly was. They are two young and talented teams. We will be hearing great things about them for years to come!

I have been thinking about errors and the aftermath of errors. (Bob does say it must be scary to be in my head!) Let me give you the two different reasons this has been in my head!

In 1999 the Institute of Medicine (IOM) published a report called “To Err is Human”. This report was groundbreaking and shined a huge spotlight on healthcare. The report stated that up to 98,000 Americans were dying annually from medical errors. To say this report caused a stir would be an understatement. I was a brand new chief nurse executive at that time, and I remember I fielded a lot of calls from friends and family! All of the professionals associated with healthcare began to critically evaluate what we did – as individual professions and also how we worked collaboratively (or not). We looked critically at errors. We explored how technology could help. If I remember correctly (and you know I am getting old!), this was also the time when Failure Mode Effects Analysis (FMEA) became a deployed tool in healthcare – how could we look at high risk processes before they became problematic. I do believe a lot of positive change came out of these efforts.

So I was a titch surprised when I read that in September of 2019 the World Health Organization came out with a new report that found that not much has really changed! Some of the quoted statistics include:

1. Globally, medical errors harm as many as 40% of patients in primary and outpatient care.

2. Globally, the annual cost of medication-related errors is $42 BILLION.

3. Globally, 1 million patients die from surgical complications.

Kathleen Sutcliffe, professor of business and medicine at John Hopkins University and co-author of Still Not Safe: Patient Safety and the Middle-Managing of American Medicine, has stated that “Twenty years later, deadly healthcare mistakes may be just as prevalent.” I will share that I have bought this book! I want to learn more about what we can do to make healthcare safer.

The other reason errors were on my mind was that my friend, the instructor extraordinaire, had texted me about one of her graduates who had made a medication error. The new graduate was devastated. The new grad needed support, and the new grad reached out to the person the student trusted, the instructor. Both my friend and I can easily remember our first error and the impact it made on us. The errors definitely rocked our worlds and our perspectives as nurses and as people. We both said our heart broke for the student. And my friend stated ” How the med errors in our lives define us for better or worse. How we (individually) respond can be career making or career breaking.” She is so right. How we as leaders handle this also can make or break our staff.

So this is teeing up the next two Phyl Phacts. One to explore how we can hold people accountable and still keep them whole! And what we, as leaders, should be doing to keep our patients AND staff safe. I think that these concepts will be important no matter industry in which you work.

I hope this starts a conversation.

Phyl