By Dr. David Mayer

First Posted on Educate the Young on 3/26/2014

David Mayer MD, Vice President of Quality and Safety for MedStar Health

David Mayer MD, Vice President of Quality and Safety for MedStar Health

Following is additional information from our team who helped share Annie’s Story, led by RJ (Terry) Fairbanks (@TerryFairbanks), MD MS, Director, National Center for Human Factors in Healthcare, MedStar HealthTracy Granzyk (@tgranz), MS, Director, Patient Safety & Quality Innovation, MedStar Health, and Seth Krevat, MD, Assistant Vice President for Safety, MedStar Health.

We appreciate the tremendous interest in Annie’s story and wanted to respond to the numerous excellent comments that have come in over YouTube, blogs and email. The short five minute video sharing Annie’s story was intended to share just one piece of a much larger story–that is, the significant impact we can have on our caregivers and our safety culture when the traditional ‘shame and blame’ approach is used in the aftermath of an unintended patient harm event. At MedStar Health, we are undergoing a transformation in safety that embraces an all-encompassing systems science approach to all safety events. Our senior leaders across the system are all on board. But more importantly, we have nearly 30,000 associates we need to convince. Too often in the past, our Root Cause Analyses led to superficial conclusions that encouraged re-education, re-training, re-policy and remediation…efforts that have been shown to lack sustainability and will decay very shortly after implementation. We took the easy way out and our safety culture suffered for it.

Healthcare leaders like to believe we follow a systems approach, but in most cases we historically have not. We often fail to find the true contributing factors in adverse events and in hazards, but even when we do, we frequently employ solutions which, if viewed through a lens of safety science, are both ineffective or non-sustainable. Very often, events that are facilitated by numerous system hazards are classified as “nursing error” or “human error,” and closed with “counseling” or a staff inservice. By missing the opportunity to focus on the design of system and device factors, we may harm individuals personally and professionally, damage our safety cultures, and fail to find solutions that will prevent future harm. It was the wrongful damage to the individual healthcare provider that this video was intended to highlight.

In telling Annie’s story, we chose to focus on one main theme–the unnecessary and wrongful punishment of good caregivers when we fail to cultivate a systems inquiry approach to all unfortunate harm events. This is the true definition of a just culture…the balance between systems safety science and personal accountability of those that knowingly or recklessly violate safe policies or procedures for their own benefit. Blaming good caregivers without putting the competencies, time and resources into truly understanding all the issues in play that contributed to the outcome is taking the easy way out. We wanted our caregivers to know we are no longer taking the easy way out…

You will be happy to know that the patient fully recovered, that Annie is an amazing nurse and leader in our system, the hospital leaders apologized to her, and all glucometers within our system were changed to reflect clear messaging of blood glucose results. We believe we have eliminated the hazard that would have continued to exist if we had only focused on educating, counseling and discipline that centered around “be more careful” or “pay better attention”. We also communicated the issue directly to the manufacturer, and presented the full case in several venues, in an effort to ensure that this same event does not occur somewhere else.

This event, which occurred over three years ago, gave us the opportunity to improve care across all ten of our hospitals. It also highlighted the willingness of our healthcare providers to ask for help because they sensed something was not right and wanted to truly understand all the issues–they also wanted to find a true and sustaining solution to the problem using a different approach than what had been done in the past. Thanks to everyone for sharing your thoughts and for asking us to tell the rest of the story. We have updated the YouTube description as well.

And, thanks to Paul Levy for opening up this discussion on his blog, Not Running A Hospital, and to those of you who continue to share Annie’s story.

For those who have yet to see the video, here it is: