For many individuals, working to find a solution and prevent future events can help. “Many surgeons involved in quality improvement or implementation science were motivated by an adverse event during their career,” Dr. Brenner said.
Explore This IssueApril 2023
Dr. Balakrishnan said that there are some key steps that can be taken to prevent the negative effects of having made a medical error. A morbidity and mortality conference can be a good place to start (Otolaryngol Head Neck Surg. 2018;158:273–279).
According to Dr. Balakrishnan, these steps include the following:
- Ensuring that our event reporting and review activities focus on system and process, not on individual blame. This encourages reporting by creating a climate of psychological safety.
- Using structured and facilitated forums to review events and identify opportunities for improvement, as well as long-term follow-up and “loop closure” (reporting back on these improvement activities).
- Separating review of provider performance from system and process review and ensuring that the former is supportive, focuses on improvement, includes effective coaching, and is kept confidential.
- As leaders, making sure that we support and implement these steps and submit to the same processes, so the rest of our teams feel safe doing so.
- Setting up robust wellness programs to support all clinicians, including those at risk for second victim effects.
“Healthcare is a socio-technical system, so we must examine systems and processes, individuals, and the interface between them, as well as how individuals interact with each other,” Dr. Balakrishnan said. “Disregarding any of these components will limit our ability to reduce errors and to cope with and learn from them when they do occur.”
Katie Robinson is a freelance medical writer based in New York.