Institute:Office of National Coordinator (ONC) Workforce Training Curriculum
Component:The Culture of Health Care
Unit:Sociotechnical Aspects: Clinicians and Technology
Lecture:Medical errors
Patient safety
Slide content:History of Error Inquiry Prior focus of inquiry for errors was on the individual and on the mistakes themselves Investigations often reflected name and blame culture Now the focus is on the systemfixing inadequacies in the system can improve patient safety Focus on system allows individuals to perform their tasks in a patient-care-optimized environment 9
Slide notes:The cause of errors must be identified so that they are not repeated. In the past, the primary focus of inquiry was on the individual who was felt to have committed the mistake and on the mistakes themselves. These investigations reflected the name and blame culture that existed in many health care systems, which punished those who committed errors. Instead of this approach, the focus is now on fixing inadequacies in the health care organization to improve patient safety. Correcting inadequacies may require changes in policies, procedures, workflow, and information systems as well as staff awareness and education. The focus on the health care organization allows health care providers to perform their tasks in an environment that is optimized to patient care rather than adversarial to the provider. The rationale for this approach is that good people make bad mistakes when they work with bad operational systems, and it makes much more sense to focus on the issue and fix the inherent problems than to place the entire blame on the shoulders of the individual who committed the mistake. 9