I recently came across Dr Goldman’s TED talk titled “Doctors make mistakes. Can we talk about that?” It’s a great talk, and its sentiment fits perfectly with the research we are currently doing in and around Errordiary.
Dr Goldman paints a picture of healthcare where there are good apples (people that don’t make mistakes) and bad apples (people that make mistakes). The current way to improve the system is to get rid of the bad apples, so we’re only left with good apples, and hence no more mistakes. Of course no one wants to be classed a bad apple, so when people do make mistakes they keep it quiet, bury it, and hide it because they don’t want to be labelled a bad apple.
Here’s the twist: everyone makes mistakes, why are we talking about good and bad apples when it just encourages unfruitful discussion (pardon the pun), forces learning underground, and why are we getting rid of so called bad apples. Dr Goldman says - if we remove everyone that makes mistakes from healthcare there would be no one left! Martin Bromiley goes further to make a moving case for why it’s good to keep ‘bad apples’ in the system, “they can spread those very personal lessons on to their colleagues, and all of them will be much better clinicians as a result, and of that there is no doubt.”
Dr Goldman’s talk doesn’t just apply to doctors but nurses and everyone else too. Obviously it is more acceptable to admit your failures when you work outside of healthcare. In her TED talk Kathryn Schulz is right when she says: that in an abstract way we all know that making mistakes is part of being human. But what do we expect when doctors and nurses don their overalls and clock in to do their shift – yes, that’s right, welcome to the super-humans! Except they’re not. There are no super-humans. Everyone makes mistakes.
Dr Goldman calls for a change in culture, to redefine doctors as humans that make mistakes, rather than super-humans that don’t. Healthcare professionals are human (shock horror), and this includes nurses too! His drive is not just so doctors and nurses can feel better about making the mistakes they would make anyway, but it is a drive for a better system. So stories are not hidden, messages are not buried, and learning is not driven underground.
Errors are absolutely ubiquitous, and so what we need are error tolerant systems and lots of learning, so as errors and near misses happen we squeeze all the learning out of them. In this view errors are not only inevitable, but they can also be a healthy part of the system, i.e. they teach people about what could go wrong so they are more resilient to these sorts of errors in the future. Much like our bodies are given a small dose of vaccination to make it more resilient to a disease, so errors can make a system more resilient to accidents. It’s not only character building, but these lessons can be invaluable and come at a high cost.
After he spoke to thunderous applause and despite being mobbed by well-wishers, Sully gave me a 27-minute lecture on patient safety I won’t soon forget.
“Everything that we know in aviation, every procedure that we have, every rule in the book, every technique that we have, ultimately is because someone somewhere died,” Sully told me.
“What we have learned are lessons purchased at great cost – many of them literally bought with blood.”
Excerpt from Brian Goldman’s article, read in full here: http://www.huffingtonpost.com/brian-goldman-md/doctors-make-mistakes-can_b_1968268.html
This request for a change in culture, is essentially a change from a blame culture to a learning or a just culture. This change means that people in the system are still accountable but there is more emphasis in finding improvements and learning than there is with finding whose fault it was. It also means running an organisation where people are encouraged to share their errors rather than hide them – to talk about them more.
So, can we talk about errors more whether we are a doctor, a nurse, a patient or a member of the general public? The theory says that we would learn more and we’d develop a safer system in the long term. However, there are real challenges with this request as doctors and nurses fear discipline, being sued and being labelled a bad apple. They’re not alone in this as many professionals outside of healthcare also do not want to talk about errors because they feel it might undermine their credibility. Also, even if doctors and nurses wanted to talk about their errors more perhaps the public would just rather not know about them. There is desire to maintain 100% belief that the healthcare systems that we depend upon are faultless or close to faultless – why worry us if we can’t do anything about it?
Talking about errors, and raising this sort of debate is something we are striving to do through Errordiary. Please have a look at the site, register and get involved – there are quite big and exciting changes for it just around the corner.
At the moment we are recruiting for focus groups to shed light on some of these issues, we want to learn from people’s views on this, if you live in or around London we’d be interested to hear from you if you’d like to take part. More details can be found here: http://www.errordiary.org/?page_id=6948