temporary fix in place — one that doesn't address the root cause —
and everything seems OK again, at least for a short time. But then,
when things heat up again, no proper corrective mechanisms are in
place, and everybody's surprised, because the mistake happens again.
The bottom line is that we need a cultural transformation in the way
we approach and think about medical errors. Since we know they're
inevitable, what can we do to eliminate as many as possible? The
answer is that we can do several things — some easier than others.
First and maybe most importantly, we need to make reporting as
easy as possible. Information is critical. Anyone who sees anything
that raises concerns needs to feel as if she can easily pass that infor-
mation up the chain of command.
The ability to report should reside on every computer in the facility
and should provide the option to remain anonymous. You want to
make it as quick and easy as possible for people to report the basics
— the who, the what, the where and the when — in 2 or 3 minutes.
The reason: If you have a single report on a single incident regarding
a single patient, it may be tough to make an evidence-based decision
as to whether it's something that warrants further investigation. But if
you have 5 or 10 reports of the same thing happening, you know you'd
better get to the bottom of it.
Granted, it may seem like a double-edged sword. If you make
reporting easier, you get more reports, and that may make it feel as if
you're doing badly. But in an industry that demands high reliability,
like aviation or health care, you need information to be able to make
decisions. People sometimes make the mistake of thinking that a
paucity of reporting is an indication that things are working well. The
opposite is true. If you don't have people reporting on things that can
be improved, chances are you don't know what's going on. Everyone
should be urged to say something whenever they see something. And
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ERRORS
