The common initial reaction when one comes across an error is to find the person behind it and blame him for the erroneous activity. However, even apparently single events or errors are due most often to the convergence of multiple contributing factors and not just a single Root cause.
Blaming an individual does not change these factors and the same error is likely to recur. Identifying root cause and preventing errors require a systems approach in order to modify the conditions that contribute to errors. People working in health care and Pharmaceutical sector are among the most educated and dedicated workforce in any industry. The problem is not bad people; the problem is that the system needs to be made better.
Following are 4 Must-have elements that can change the way an organization can identify and eliminate underlying problems:
1. A Highly practical and usable error-reporting system
That is, it must be intuitively designed and allow for rapid capture of events (i.e., within two to five minutes). Employees simply cannot and will not take the time to enter an event if that act requires them to deviate from their routine allocated tasks for an extended time.
2. Leadership in the organization must model a “Just Culture.”
Just Culture is defined by the European Commission as “a culture in which front line operators or others are not punished for actions, omissions, or decisions taken by them that are commensurate with their experience and training, but where gross negligence, wilful violations, and destructive acts are not tolerated.” If Just Culture is not promoted, front-line providers will resist sharing error details if they fear it will compromise their professional standing.
3.Data must also be collected post incident.
Data must be collected on the back-end to ensure that the improvements to the system that are introduced have been successfully integrated into the delivery of care and serve the purpose for which they were intended.
4. Delegate proficient workforce to handle investigations.
Instead of letting the supervisors handle the error incidents, it is highly recommendable to handover the responsibility of error investigations to an experienced and competent employee who can exclusively work on it. The problems cannot be solved by someone who just looks to close an error document to promptly go back to the routine job activities.
Without these four elements, the organization’s quest to deliver unfailingly compliant investigations will very likely be unsuccessful. Ultimately, the ability of an organization to learn from errors and events, and to focus their efforts on recurring errors, depends upon judicious use of their event-reporting system.
