Should disciplinary action be taken
against those who make multiple or catastrophic errors?
From the April 8, 1998 issue
Non-punitive reporting systems and handling employees who
make multiple or catastrophic errors are frequent topics raised
by health care managers and practitioners who contact us.
This subject was discussed at length recently during a conference
call led by Lucian Leape, MD, of the Institute for Healthcare
Improvement (IHI) and Judy Smetzer, RN of ISMP. Both are serving
as faculty for an ADE prevention collaborative now underway
through IHI. The need for leadership understanding and a solid
commitment to a non-punitive approach to errors were stressed
during the call. Employees are blamed for errors when administrative
leadership is unaware of the significant influence of the
system on individual performance. A non-punitive approach
is not possible unless there is support from top leaders -
all the way up the leadership chain - who truly understand
that errors are just symptoms of a "diseased" system, and
that error prevention efforts must be directed at the weaknesses
in the system, not at individuals.
Several techniques were suggested for creating a non-punitive
environment that supports increased error reporting. A confidential
reporting system where everyone understands that errors will
not be linked to performance appraisals is critical. Make
it easy to report errors, reward error reporting and provide
timely feedback to show what is being done to address problems.
Apply a non-punitive approach to errors consistently! If even
one person is disciplined for an error, mistakes will be hidden.
Find alternate ways to evaluate employees, based not on errors
or lack of making mistakes, but on positive measures that
evaluate an employee's overall contribution to the organization.
A non-punitive environment is really tested when an organization
is confronted with an employee who makes multiple errors or
is involved in a catastrophic error. We often find it easier
and in our nature to blame individuals and resort to familiar
solutions: counseling, disciplinary action, enforcing rules
or developing new rules. There is little or no remedial value
in doing so and the easy way out often leads back to problems
that persist or worsen. In fact, when the only action is punishing
individuals for errors, this can actually be dangerous to
an organization. It leads to the ever increasing need for
more of the same familiar remedies, or the philosophy of "what
we need here is a bigger hammer." The root causes of problems
are not identified and the system is weakened even further.
Organizations face considerable pressure from the public
and the legal system to discipline individuals for mistakes.
Nevertheless, even with employees involved in multiple or
catastrophic errors, there is little advantage to terminating
them. It inadvertently sends the message that the organization
has hired a defective employee and has not exercised good
judgment in allowing the employee to provide care in the organization.
Rather, it is more important to determine why errors are happening
and take action to effectively prevent these errors or minimize
their consequences. The goal of patient safety is best served
with a non-punitive environment that places more value on
reporting problems, so they can be remedied, than pursuing
the largely unprofitable path of disciplining employees for