“The single greatest impediment to error prevention in the medical industry is that we punish people for making mistakes.”                                    Lucian Leape

Patients always take a leap of faith when they enter the hospital and trust in the system that will keep them safe. Every clinician I know views this trust as a great honor. At the same time, those that are honest would all acknowledge that we betray their trust every day with a system that does not prioritize their safety. Twenty years after first introducing the nationwide problem of patient safety, it remains common knowledge that 1 in 7 patients still suffer a preventable error in the hospital . In addition, hospital scores for key safety measures have failed to show any meaningful improvement over time . News headlines continue about a jumbo jet full of patients dying every day due to preventable errors.

One might expect the hospital leaders that are ultimately responsible would be depressed about all that, particularly those damning headlines. Such a poor record of accomplishment should trigger a sense of urgency, a burning platform for change. It is reasonable to expect hospital leadership to do anything to empower their front line employees to speak up to improve conditions for safety. Unfortunately, data show the opposite. Surveys of the safety climate at US hospitals show that a third of the staff on the front lines think mistakes do not lead to positive changes, half are afraid to question their superiors and over half feel there is a punitive response to error. Even more problematic, the leaders accused of being punitive and unapproachable by their staff don’t see the problem in the same way. Administrators and top managers perceive safety in their hospitals as “good or excellent” in these surveys 25% more often than those on the front lines.

One appreciates the gravity of these survey findings by comparing the system of safety in hospitals to that of naval aviation, which has been exceptionally consistent in avoiding the catastrophic errors inherent in landing jets on aircraft carriers. The crews on aircraft carriers answered these same questions negatively less than 10% of the time. Surveys reflect that their mistakes are celebrated as a chance to learn and they feel free to speak up without risk of being punished. The difference negative responses between hospitals (33-50%) and aviation (<10%) is very meaningful because a working safety culture requires high uniformity of safety attitudes and experiences among the team. One or two rotten apples can be dealt with but just a few more spoils the bunch.  Even more important, the leaders and those on the front lines of an aircraft carrier showed no difference in perceptions of safety.

Leadership is about inspiring a team to reach a common goal. The most fundamental goal of medicine, and therefore for a hospital, is to first do no harm. We are morally bound to first keep patients safe. Hospital leaders have been either clueless or willfully ignorant of evidence that they cannot or will not address. This disconnect suggests hospital administrators are unmoved or unaware of the seriousness of the problem, probably because it might hurt the next quarter’s bottom line. The saddest thing is that safe care always improves the bottom line, just not over the next quarter.  The best way to change a poorly designed system is to pursue full transparency from the staff.  No one should stay quiet about their concerns.

“I don’t condone treatment that is unsafe and certainly don’t agree that I am a relevant culprit in patient harm.  Inappropriate decisions and actions of nurses, physicians and/or other front line staff are what affect safety.  Sometimes the love that these dedicated providers have for their patients blinds them to the realities of running a hospital.  My peripheral influence on safety is to use resources more wisely than any given physician might so that we make sure all patients in the hospital have equal access to safe care.  Sometimes that involves tough decisions, like turning down the latest (and expensive) fad alleged to improve patient safety.  Moreover, transparency might work in Silicone Valley at places like Google, Pixar and Bridgewater but it has a greater chance of being disruptive and causing more patient harm than good in a conservative workplace like a hospital.  Finally, my door like any CEO “is always open” if a nurse or doctor wants to bring up issues that are harming patients.  It is ridiculous to suggest that anyone would be fired for doing so.”                                              Response of a typical hospital CEO

Each of these points is reasonable except the final one.  When it comes to speaking up it is the perception of a punishment rather than the reality that is more important.  This fear serves as a sober reminder that the halls of the typical US hospital are haunted by the ghosts of naïve but sincere nurses who have been fired over the years for speaking up about problems in the past.  This has led to a new “silent majority” of firsthand witnesses to unsafe systems that harm patients while making everyone helpless to change it. A CEO must accept that getting people to speak up requires actions to right the past wrongs.  Without such action, nurses will be caught in a conflict between what they want to be and what their environment allows them to be. Over time, this takes its toll.

In 1983, the academy award for Best Actress went to Merrill Streep for her role in Sophie’s Choice. Both the title of the movie and the reason for the award are based on a single 4 minute climactic scene. A mother of two standing in line at Auschwitz was forced to choose which child would be sent away by a Nazi guard. If you haven’t seen the movie, here is a clip of that scene. Every day that healthcare providers come to work and nothing changes, they are thrust into healthcare’s modern version of Sophie’s choice. This time the drama is a choice between their patients or their career, a selection that leaves them like Sophie – damned either way. On the one hand, they can speak up and be fired or ostracized as a “trouble maker”. On the other hand, they can remain silent and accept that they failed to advocate for their patient. If they do that, it means giving up their vocation and accepting that they now just do a job.

Sophie never recovered from guilt and depression and killed herself soon after her choice.  Maslow’s hierarchy of needs predicts that a nurse worrying about job security is unable to be engaged in their work. Asking them to have any real concern about things like patient satisfaction or their experiences is not going to work and likely to backfire.  They may have lost all connection to their “north star”, the Nightingale Pledge, but it is not required that they suffer Sophie’s fate.  In the next post, I will describe the ways we can prevent that from happening.