Why Medical Errors Persist: Developing a “Second Nature” Culture

 “Organizations create shadowed places in which mistakes may go unseen and no questions are ever asked.”

Mary Douglas, How Institutions Think, Oxford University Press, 1982

Errors, Errors and More Errors

I’ve seen a lot of medical errors in my time as a clinician, and I’ve heard about many more as an executive:

? There was the time a surgeon performed surgery on the wrong leg.

? There was a patient that was given the wrong blood, and she went into profound shock. 

? There was a patient that was brought into an MRI suite, but the technicians forgot to clear the room of a metal oxygen container, and that container flew into the patient.

? There was the time an ER nurse forgot to remove an IV from a patient’s arm before being discharged. And a day later that same patient came back via ambulance having overdosed by mainlining heroin through that very same IV line.

? There were the triplets in the neonatal ICU, all of whom received an adult dose of heparin and all three died that same day. (Mom is pictured above.)

Many of these same types of errors are still occurring, and at alarming rates. And they are occurring by the thousands every year.

Medical Errors as a Leading Cause of Death

Sadly, medical errors are rampant. Medical errors are the 3rd leading cause of death for all Americans. Only heart disease and cancer cause more deaths. Medical errors are almost entirely preventable, yet they account for over 250,000 deaths per year. And medication errors account for 1.5 million injuries every year—which is 4,110 medication errors every single day.

The Difference Between Fixing an Error and Learning From Errors

And while hospitals do spend time trying to figuring out what went wrong during a specific error, often, after such an investigation has concluded, the finding is that the mistake was ‘one off,’ or unique, and therefore impossible to develop systemic change to prevent it from happening again.

But while organizations do spend time responding to a specific error, rarely does the organization spend time thinking about how it learns from its errors. It’s almost as if organizations view errors as goblins to be “tucked away into “shadowed places.” 

Errors are not fully utilized and systemically understood so as to be of future learning, and therefore, valued.

No. Errors are not valued, nor are they systemically understood. They are viewed as failures to be quickly and secretly discussed, without assigning responsibility in the event ‘responsibility’ is mistaken for ‘blame.’

Learning From Errors: Developing an Organizational ‘Second Nature’

So, given the stakes and consequences at hand when organizations do not learn from their mistakes, what is the be way to bring about and then sustain permanent systemic change?

 How do knowledgeable leaders within an organization create a paradigmatic shift away from dysfunctional organizational procedures that are already in place; or worse yet, simply in place by default, without any conscious thought behind how to manage a problem? 

What precisely, is a ‘healthy, learning organization?’ (I define “healthy” as an institution that does not hide errors, but rather, puts into place formal structures and procedural scaffolding, such that all individuals working within the system know what to do, how to do it, and finally, how to sustain this type of healthy milieu.)

Put simply, a healthy organization finds it “Second Nature” to appropriate, immediately, and without thought, adaptive responses to problems.

What are the mandated procedures to be followed in order to provide a uniformity of understanding within the system; a flow chart, if you will, of how to triage, “manage” and eventually, prevent the same outcome from occurring over and over again?

Three Steps To Begin Learning How to Learn From Errors

I believe the first step is to acknowledge that the medical industry has a problem.

Each organization—whether it’s a doctor’s office or hospital—has a problem with errors. (Perhaps each and every meeting should open with this reflection…) I’ve been in too many meetings where administrators defend their low scores because of the belief that errors are simply part of the deal of getting health care. I certainly would not accept this explanation from a commercial pilot nor do I accept it here.

Then, the second step is creating this ‘Second Nature.’

The Second Nature is one that finds appropriate, immediate, adaptive responses to problems. And who are the people that know where the problems are and where the processes break down? The nurses, doctors, technicians and others (‘front-line operators’) who deliver that care. We should be encouraging those ‘front-line operators’ to develop formal structures and procedural scaffolding that best suites the ‘what’ and ‘how’ of the problem. Front-line operators know what to fix, they know what is broken, but they are rarely given the formalized time and resources to be the solution.

The third step is to normalize the role of front-line operators in developing the adaptive responses and solutions to everyday errors. 

Front-line operators are the ones closest to the system’s daily work flow and they are the only ones who can develop the ‘second nature’ culture of learning, adapting and improving in order to prevent the same outcome from occurring over and over again. They need to be resourced with time to do this type of work.

 Moving Cultural Boulders

I realize that these three steps represent a large cultural and structural change—for example, how are union-based workers supposed to find time doing ‘non-clinical’ care activities if such work is not in their contract? Will hospital administrators pay for this ‘non-clinical’ time? Will hospital administrators realize that their role is to enable and support these clinicians rather than trying to find answers to problems that they do not live and work every day?

In order to do these three simple steps, several ‘cultural boulders’ would have to be moved out of the way—administrators would have to adjust aspects to their work (and professional identify), like collaborating with clinicians to find solutions. And the clinicians would have to be paid to do these very valuable but non-clinical activities.

My great hope is that, what is now envisaged as “bold and radical” system change will one day be seen as simply natural and normative.

About the author: Julie Kliger is recognized by LinkedIn as a "Top Voice" in Health Care in 2015 & 2106, & 2107. She is a Healthcare ‘Strategic Realist’ who is passionate about improving health care and improving lives. She specializes in future-oriented healthcare redesign, translating bio/med-tech into legacy industries, implementing new care models and strategic change management. She is an adviser, clinician, health system board member, speaker and author. 

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