Preventing Human Error in Healthcare: The Power of a “Just Culture”

Dr. Josh Williams and Emily Wood

On July 2^nd of 2021, two people at the University Hospital Cleveland Medical Center were undergoing surgery to receive new kidneys to save their lives. And then something went wrong.

“The health system confirms a kidney meant for one patient was mistakenly transplanted into the wrong person. Now we’re told the mistake wasn’t noticed until the second operation. UH won’t confirm how far along the surgery was when the transplant team realized they had the kidney intended for the first patient. Two “caregivers” — UH would not disclose if they are doctors, nurses, or other staff — are off the job pending an investigation.”¹

Understand that this is not a substandard hospital. The Cleveland Clinic is the fifth best hospital for adult care in America.² Unfortunately, this is not an isolated case across the country. A quick Google search of hospital error yields a myriad of cases like improper medications being administered, anaesthesia missteps, and even the wrong limbs being amputated. In fact, 400,000 deaths each year are attributed to hospital mistakes.³

So how do we fix this? Is firing people really the answer?

Reality Check

The issue of human error is extremely complex, especially in the COVID era. Neuroscience research now shows that stress decreases brain volume and causes impaired decision-making, judgment, attention, and memory. In fact, the American Psychological Association estimates that stress is associated with 60-80% of all workplace incidents. Fatigue also plays a role in human error. Overly fatigued or sleep deprived employees are 70% more likely to experience a workplace safety incident.⁴

Back in 2016, the Head of Spinal Surgery at the Boston Medical Centre went to eat in his car prior to an emergency surgery but ended up falling asleep. The surgery was successfully performed by the chief resident, but five years later, state regulators fined the surgeon $5,000 and ordered him to complete five continuing education credits in professionalism. An experienced surgeon and professor with no prior complaints was told he “engaged in conduct that undermines the public confidence in the integrity of the medical profession.” While no one wants their surgeon to fall asleep and miss their surgery, surgeons are people too. They work long hours, are under enormous amounts of stress and are subject to the same cognitive limitations as everyone else.⁵

Hospital staff have had to balance long hours and insufficient sleep for years. Now, with dwindling personnel noted in the COVID era, unprecedented levels of overtime hours, pressure and stress for hospital staff has been noted. This July alone, more than half a million hospital staff quit their jobs.⁶ After more than a year of battling COVID, healthcare workers are burned out and 1 in 3 healthcare workers are currently considering leaving the healthcare field due to the daily stress and pressure⁷. By working to create a “just culture” in healthcare environments, employees will be provided a lifeline, where they can operate in a fair and supportive environment. In a just culture, organizations acknowledge they are accountable for creating the environment in which their employees work, and mistakes are often the product of faulty organizational cultures, rather than only brought about by the person(s) directly involved.

Just Culture

Within a “just culture,” human error is not viewed as an occasion to punish but rather an opportunity to learn and improve. In this framework, safety is not viewed as the absence of events, but rather the presence of solid, reliable defenses against inevitable human error. While this doesn’t (and shouldn’t) eliminate personal accountability, there is a much greater emphasis on establishing a true learning culture. In these environments, people speak up with each other more to share best practices, discuss lessons learned, and provide helpful feedback.

This creates a more proactive culture to actively mitigate errors. It also changes the narrative from “blame and train” to “fix the system” when mistakes happen. In this environment, punishment is rare and is reserved for willful negligence or repeated, intentional violations.

When a just culture is actualized:

-the work environment is more positive and supportive,

-best practices are better shared across the organization

-close calls and minor injuries are more openly discussed, and

-there’s a decreased likelihood of incidents with patients and employees.  

Human Performance Tools

Human performance (HP) tools should be used to promote a true learning environment within the just culture context. HP tenants hold that human error is inevitable and is a predictable outcome of human beings operating in flawed environments.⁸ Within this framework, active steps are taken to improve system factors to prevent human error.⁹

Human performance tools like pre-job briefs and observation checklists are used to anticipate, mitigate, and analyze human error before, during, and after the work is done. With these (and other) HP tools, there is an ongoing emphasis on:

-anticipating where human error is most likely,

-speaking up respectfully when errors are identified and observed,

-identifying trends when and where errors are most frequently occurring,

-taking active steps for future error mitigation, and

-advertising improvements to demonstrate commitment to a true learning culture.

These tools help prevent incidents with both hospital staff and patients. A sustainable feedback loop is created to make ongoing improvements based on employee feedback. Two case studies demonstrate the efficacy of HP tools to improve safety in healthcare. In a study from Johns Hopkins, the introduction of HP pre-job briefs with surgeons resulted in a 19% reduction in communication breakdowns and an 82% decrease in operating delays. This resulted in more efficient and safer operations at the hospital. Researchers concluded that this HP tool should be expanded to other areas to improve overall hospital profitability and safety.¹⁰

As part of the World Health Organization’s Safe Surgery Saves Lives Program, the use of HP checklists with surgeons was associated with a significant reduction in major postoperative complications after inpatient surgery. This resulted in a 47% decrease in mortality and 36% drop in morbidity. Researchers concluded that these checklists helped save lives by a) reminding operating room staff to check key details during operations, and b) encouraging increased teamwork and communication.¹¹

Preventing Human Error in Healthcare: Bottom Line

Cultivating a “just culture” benefits health care organizations, workers, and patients. Bringing issues to light in a supportive environment, instead of sweeping them under the rug, boosts ongoing learning and improvement. Successfully implementing human performance tools brings “just culture” to life. These tools help improve organizational culture, reduce the probability of human error, and may provide you more comfort if you’re ever in need of a new kidney.

At Propulo, we help healthcare organizations develop and implement effective HP processes to reduce human error and prevent incidents.

References

1. https://www.news5cleveland.com/news/local-news/investigations/uh-kidney-transplant-mistake-not-noticed-until-second-patient-was-in-operating-room-sources-say  
2. https://health.usnews.com/best-hospitals/area/oh/university-hospitals-case-medical-center-6410920      
3. https://centerforhealthjournalism.org/2016/05/09/3-horrific-medical-mistakes-scandalize-profession
4. Suni, E. & Singh, A. (2021). Excessive Sleepiness and Workplace Accidents. https://www.sleepfoundation.org/excessive-sleepiness/workplace-accidents
5. https://www.bostonglobe.com/2021/10/27/business/boston-medical-surgeon-fined-leaving-operating-room-eat-his-car/?outputType=amp
6. https://www.dallasnews.com/business/health-care/2021/09/24/as-covid-rages-more-health-care-workers-are-quitting-and-job-openings-hit-a-new-high/
7. https://www.washingtonpost.com/health/2021/04/22/health-workers-covid-quit/
8. Conklin, T. (2012). Pre-Accident Investigations: An Introduction to Organizational Safety. Ashgate Publishing Company, Burlington, VT.  
9. Williams, J. & Roberts, S. (2018). Integrating the best of BBS and HOP: A holistic approach to improving safety performance. Professional Safety, 45, 40-48.
10. Nundy, S., Mukherjee, A., Sexton, J. B., Pronovost, P. J., Knight, A., Rowen, L. C., & Makary, M. A. (2008). Impact of preoperative briefings on operating room delays: A preliminary report. Archives of surgery, 143(11), 1068-1072. 
11. Haynes, A. B., Weiser, T. G., Berry, W. R., Lipsitz, S. R., Breizat, A. H. S., Dellinger, E. P., and Merry, A. F. (2009). A surgical safety checklist to reduce morbidity and mortality in a global population. New England Journal of Medicine, 360(5), 491-499.