Is It Dirty or Clean — More

I have told the story about the supposedly clean IV pump in the dirty utility room — see previous post — to a lot of people over the course of  this last week.  Kind of like a focus group exercise.  Can you guess what most people immediately say?  The usual.  Blame the nurse.  What kind of stupid person would think a pump that is supposedly clean is really clean if it’s in a dirty utility room?   In this instance, as in so many others, the game is blame the individual, in this case the nurse.  This in spite of more than two decades of research telling us that creating ambiguous situations like the one I just described is a recipe for smart and well-intentioned people to make catastrophic errors. This is  particularly true when people work in high stress environments where they are over-worked and fatigued(latent pathogens if there ever were ones) as most nurses, doctors, and others who work in health care are today.  In his book The Human Factor, Kim Vicente warns about precisely these kind of ambiguous conditions and argues persuasively that it’s useless to blame people when the environments in which they work create the perfect storms that produce error. Lucian Leape, the physician who has done so much to raise our consciousness about the need to stop blaming people and start focusing on system problems, has consistently warned against blaming health care workers for system problems.  How many times do we need to hear about James Reason’s Swiss Cheese Model of Error to stop putting the blame on people rather than systems.  Obviously, if an error occurs because a person is incompetent or unmotivated then there is an individual problem and the individual should be held accountable.  But even in this case — unless a person is down right malevolent — we find a system problem.  If a nurse is so over-worked and over-tired that he or she ignores safety practices, this is a system problem.  Why is the RN working a 12- plus- hour shift when we know errors occur after ten?  Why is her/his patient load so high (particularly given escalating patient acuity in American hospitals) that the RN no longer has the mental energy to be attentive?  If the RN is incompetent that’s even more of a system problem?  Who hired her/him?  Did she/he get enough mentoring, orientation, help from others on the unit?  We are very quick to discuss individual competence or incompetence but reluctant to talk about institutional competence or incompetence.   The amount of latent pathogens permitted in our hospitals suggested an epidemic of institutional incompetence.  But even these terms are dangerous since one again risks blaming the people who run institutions rather than the systems of thought that determine how we all think about and prioritize safety.

But back to this case.

Clearly the institution in question needs to reassess not only its policies but its practices.  Clean stickers need to be taken off once a piece of equipment is in use.  People need to learn to do that.  Anything in a dirty utility room needs to be considered dirty no matter what its sticker says.  If that means spending the money to re-clean something that’s already clean, so be it.  If we cannot afford to spend money on safety, then patients will continue to suffer and die unnecessarily.   I am sure human factors engineers like Kim Vicente or patient safety experts like Lucian Leape  would have even more to say about this.  My take home message is that we have to stop blaming people and start figuring out how to be institutionally and culturally mindful about safety.