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By DAN REYNOLDS, senior editor of Risk & Insurance®

The news out of Hartford and West Haven, Conn., last month was startling.

Jose Goncalves, 60, of Hartford was blinded in one eye during his outpatient operation for cataracts when a third-year resident mistakenly injected an anesthetic into his eye instead of behind it. As a result of the misplaced injection, Goncalves' eye exploded.

Reporting on the error, the Hartford Courant published the name of the resident, adding that she was immune from legal action because she was a federal employee. We won't name the resident this time for the following reason:

In April, it was reported that a long-time critical care nurse, Kimberly Hiatt, had taken her own life after being disciplined in the aftermath of another medical error at Seattle Children's Hospital.

Hiatt, 50, was escorted from Children's in September 2010 after reporting to colleagues that she had committed a gravely serious medical error: injecting 10 times the appropriate amount of calcium chloride into a baby with severe heart problems.

The eight-month-old baby later died. Though tying Hiatt's error directly to the death of the baby, who was already weak, would be difficult, Hiatt was nonetheless terminated from her job, according to news reports. Despondent over the destruction of a career she loved, she took her own life.

The Washington State Nurse's Association took exception to the way the hospital handled its treatment of Hiatt, and the nurses' association negotiated a confidential settlement with the hospital on Hiatt's behalf.

TRUST FOR ALL

As important as it is to report on medical errors and to reduce them, it is equally important to create a culture of trust, said Dr. Paul Schyve, senior vice president, health improvement, with The Joint Commission, an Oakbrook Terrace, Ill.-based healthcare accrediting and certification organization dedicated to patient safety and the reduction of medical errors.

In what's known in healthcare risk management as the "just culture," errors that are a result of gross negligence--that is, a person knows what they are doing is wrong and dangerous and does it anyway--should result in discipline. If the healthcare worker in that case is not disciplined, then other workers will lose faith in leadership.

But there are many instances of errors that result solely from the fact that we are all human and we all commit errors.

"There are errors that are built into the way our brains work," Schyve said.

"Don't blame and shame, but rather, counsel some people, provide them with support because they are suffering. And look at how you might be able to change the system," he said about providers in those cases.

Another category of error occurs when well-intended workers go against safety policy to save time or to lighten their workload, and they may not be aware of the risk they are introducing into the process, Schyve said.

"You've got to counsel them and help them understand that what they were actually doing was introducing risk which they didn't fully appreciate. But you are not blaming them and shaming them for what happened," he said.

For such a just culture, or a culture of safety to flourish, the leaders of an organization must be committed to it and lead by example, Schyve said.

July 5, 2011

Copyright 2011© LRP Publications