What’s the best way to talk about it when something goes wrong with patient care?
The Minnesota Department of Health this week released its annual report on “never” events that occurred at Minnesota hospitals and surgery centers over the past year, and as usual I had an internal debate over whether to use the term “adverse event” or “medical error” or, simply, “mistake.”
You might ask, “What’s the difference?”
But if I’ve learned anything from a decade’s worth of reading and studying the yearly adverse health events report, it’s that none of this is as straightforward as it seems.
The incidents catalogued in Minnesota’s adverse health events report represent the most serious things that go wrong in hospitals – wrong-site procedures, advanced-stage pressure ulcers, patients who die by suicide while in the hospital, serious medication errors and so forth. By definition these are considered “never” events – events that should never, or only rarely, happen in the hospital.
The world of patient safety is a huge ecosystem, however, with many layers that are less easy to categorize. Does an error lie behind every bad event or is it more complicated than this? Those who work in patient safety would say to beware of oversimplification.
Not all adverse patient events are directly the result of a mistake. Not all mistakes lead to adverse events.
For that matter, not all adverse events end in harm, although plenty do and patients can be seriously disabled or even die as a result.
Sometimes it’s the individuals delivering the care who are at fault. More often, it’s the system itself that’s faulty and vulnerable and sets people up, patients and health care professionals alike, for something to go wrong.
And sometimes, in spite of everyone’s best efforts, in spite of doing all the steps correctly, things just don’t go well.
Teasing out these nuances is one of the challenges in patient safety, especially when it comes to how the public perceives and talks about patient safety. It’s still difficult for hospitals to speak openly about adverse events, partly because it’s painful to do so but also partly because of the barrage of blame and judgment that’s likely to be unleashed.
This isn’t to say providers are entitled to a free pass whenever a patient is harmed. Accountability is necessary, always. But there’s a difference between holding people accountable and being harshly punitive. When the energy is focused on blame, the attention can be deflected away from learning what went wrong, why it happened and how it can be prevented from happening again.
Because, in the end, isn’t that what everyone wants? To learn, so the vulnerabilities can be fixed and future patients are less likely to have something go wrong with their care.
One of the big lessons from 10 years of experience in Minnesota is that reporting and open discussion about adverse events is making health care measurably safer. At times the progress has been achingly slow and at times it has gone backwards, but the overall trajectory has been in the direction of improvement.
This doesn’t happen, though, unless there’s a rational conversation about it. At some point we all need to make it less scary for people to ‘fess up so the real work of learning and improving and making care safer can take place.