Nonpunitive policy helps find real cause of errors

A nonpunitive policy on investigating errors yields better results, especially if you couple it with an amnesty period that promises employees can confess their mistakes without threat of punishment, says Elaine Shaw, director of quality resources at Good Samaritan Hospital (GSH) in Vincennes, IN.

GSH established a nonpunitive environment regarding clinical errors in 2000, Shaw says, but the policy didn’t really take hold with staff until the hospital added a promise of amnesty in 2001. The policy helps the hospital conduct more thorough and productive root-cause analyses, she says.

"It makes people more willing to open up and walk through the process," she says. "We realized we could talk about a nonpunitive approach but we had to assure our employees we were practicing it. The amnesty statement helped get that message across."

The policy states clearly that the hospital focuses on investigating systemic failures instead of punishing individuals who make mistakes, and it gives employees 48 hours to report their own errors or any others they have knowledge of without any fear of punishment.

Must get word out to staff

GSH risk manager Judy Johnson, PhD, RN, CPHRM, says the nonpunitive policy has changed the way the hospital addresses patient safety. Educating employees about the approach is key, she says, because it runs counter to what many health care providers assume about how clinical errors are investigated.

The most experienced employees may be the hardest to convince, she says.

"I talk with every group of new employees that comes through and it’s easier to get through to them, to create that mind set coming in, vs. trying to convince someone who’s been here for 20 years that this is how we’re doing things now," she says. "It’s part of our culture now, but it’s still important to keep getting that message out."

Shaw and Johnson point to a recent root-cause investigation they conducted at GSH as an example of how the hospital’s culture has changed. The incident involved a patient given the wrong drug intravenously, and Shaw says that in past years, the investigation would have been very "blame-oriented."

IV bags hung too high

But under the hospital’s nonpunitive policy, the incident was studied to determine how the employee was able to make the error. Using the TapRooT system from System Improvements in Knoxville, TN, the hospital conducted an investigation that identified these root causes:

  • The IV bag design had changed so that a drug previously in a differently sized bag was the same size as other IV bags.
  • The font and type used to label the bags was small and could easily be misread.
  • The nurses hurried because of unnecessary, repetitive paperwork that could be reduced to allow more time with patients and in administering medications.
  • IV bags were being hung unnecessarily high, which made the labels hard to read for shorter nurses, especially if they wore bifocals.

To correct those systemic failures, the hospital increased the font size on the IV bag labels, started putting the patient’s name in bold type to make it easier to find on the label, and lowered the height of the IV bags. The bags used to be hung high because they depended on gravity to feed the solution through the tube, but these days most IV bags are hooked to pumps and don’t need any elevation to work.

"That root-cause analysis was different in many ways from any that we had done before," Shaw says. "We never would have discovered that the problem was caused by an IV pole six feet in the air if we hadn’t had those people sitting around the table. That’s a really simple thing to fix, but no one thought to think that we don’t need it six feet in the air any more."

Johnson says that type of root-cause investigation is a good example of how she explains the process to employees.

"It’s very important for them to know that we are looking at the process, instead of I want you to come to my office so I can tell you what you did wrong," she says. "If people understand that they are much more willing to be a part of this effort to study our processes."

But the nonpunitive policy does not mean that employees are never held responsible for their own actions, Johnson says. The policy states that employees can be held personally responsible if there is any evidence of criminal intent or if there is a pattern of behavior that could threaten patient safety.

"They can be held accountable in the sense that we look at trends and patterns, and we look at the seriousness of what happened. For patient safety, we can’t just say we never look at whether you made a mistake," she says. "But our first approach is to create a better environment in which that mistake won’t happen again. It’s not as simple as saying, You made a mistake, so you’re fired.’ In most cases, that doesn’t really get to the root of the problem."

Good staff may take blame fast

The nonpunitive policy is all about attitude and how the hospital approaches error investigations, Johnson says. If a nurse with an excellent history makes a serious mistake one day, she says the nonpunitive approach is to find out what was different about that day rather than assume that the nurse just performed poorly. Johnson cautions that excellent employees are sometimes the least likely to offer systemic causes for their mistakes. They’re so remorseful that they just admit it was their fault and don’t want to sound like they’re making excuses.

If you dig deeper, you might find out that she was on the phone with a doctor discussing a bad case, she was upset, and at that moment, a lab report came in. She’d never missed a lab report before; but on that day, she was preoccupied and overlooked the report.

"It was a very serious error, but are we going to terminate this woman? No, we’re going to investigate how it happened and figure out how we can prevent that same scenario in the future," she says. "Usually, these people are so devastated that they punish themselves plenty. There’s no benefit in us punishing them as well."

But of course, that doesn’t mean that all employees are excellent and all mistakes are aberrations.

"If we find that the employee is making 10 mistakes a week, we have to look at what we can do to help that person with further education, or we might decide that we have to take that employee off of the unit for patient safety," she says. "A nonpunitive environment doesn’t mean that we never work with individuals to improve or that an employee could never be let go."