The names change, the blame's the same

Pam
Pam Frampton
Send to a friend

Send this article to a friend.

"Blame is just a lazy person's way of making sense of chaos."
- Doug Coupland,Canadian novelist

If the premier and the health minister truly want to clean up the "toxic" atmosphere in the labs at Eastern Health, then they should stop poisoning it.
Ever since the breast cancer testing scandal went public, Jerome Kennedy's and Danny Williams' response to dealing with problems in the health-care system has been to come out swinging.
When the Cameron Inquiry was at the height of its work, they disparaged Justice Margaret Cameron and complained the inquiry was costing too much money.
When bungled communications at Eastern Health made it look like they were trying to hide information from the public, the response from the premier was that officials at the health authority "should be shot."
Last week, Kennedy was calling pathologists "childish."
Seriously, do Kennedy and Williams have any settings beyond "tough talking," "outraged" and "savage"?
Obviously Kennedy couldn't sustain the impressively calm demeanor he displayed during the H1N1 pandemic and he's slipped back into attack-dog mode.
Williams? Well, he rarely sees a fight he doesn't want a piece of. Sometimes that works to this province's benefit, and sometimes it simply does not.
Surely they must realize their regular hissy fits at the expense of medical professionals do nothing to restore public confidence in the system. Nor do I imagine it does much in the way of convincing the extra nurses and specialists we need in this province to call up looking for job application forms.
(And surely to God it can't be good for the ministers' own blood pressure.)

Addressing problem
It's time they gave up all the chest-pounding and gnashing of teeth and addressed the real problem.
It's not the people at Eastern Health that are to blame, it's the system.
And the system won't ever be fixed if the government's response continues to be reactive and sparked by blistering anger instead of proactive and fuelled by reason.
Does anyone really think an individual clinical chief was behind the cyclosporine errors, or were those errors indicative of a bigger problem?
A local nurse I spoke to this week pointed out an interesting column that ran in The Wall Street Journal on March 16 by Laura Landro. It described how a hospital in Madison, Wis., decided to adopt a new workplace model after a medical error led to the death of a 16-year-old patient, and the nurse who inadvertently made the mistake had her career and reputation ruined.

Systemic errors
In the Wisconsin case, while the nurse in question did make errors, the system was also partly to blame for not having measures in place to ensure nurses received the proper training and were not overworked.
After that incident, the hospital adopted what's called a Just Culture Model, which Landro explains, "stresses finding a middle ground between a blame-free culture, which attributes all errors to system failure and says no individual is held accountable, and overly punitive culture, where individuals are blamed for all mistakes."
The model was developed by an American engineer, David Marx, who works for an enterprise risk management company, Outcoming Engineering.
One of his colleagues, K. Scott Griffith, explains the approach in a December 2009 article in The Joint Commission Perspectives on Patient Safety:

"Rather than only react to the actual harm involved in discovered events, an organization with a Just Culture assesses the daily risks inherent in its operations and works toward maximum reliability to prevent future adverse events, relentlessly improving both system design and the quality of collective behavioral choices."

Just Culture workplaces also recognize the difference between a mistake that is made inadvertently and those that are made by employees who wilfully ignore safety rules or otherwise behave recklessly in carrying out their duties.

Patient information
There is wilful action - like last week's privacy breaches at Eastern Health where staff reportedly accessed patient information that was supposed to be confidential, and then there was a breach of patient confidentiality that occurred by accident.
Some people deserve to be punished, but some don't.
And in some hospitals, not only does the administration not punish the employee whose inadvertent error led to a patient being harmed, they actually provide support and counselling to the employee, who can end up with lifelong trauma as a result of having hurt someone in their care.

Laying blame
Think about it: we wouldn't charge a driver who accidentally struck a pedestrian running across a dark stretch of road at night, so why do we demand to lay the blame on someone's head in the case of a medical error where the system might be at fault?
Wilful neglect is one thing, making mistakes because the tools you are given are flawed is something else.
One thing's for certain, if the premier and health minister truly want an environment at Eastern Health that's non-toxic, they should take the first steps towards creating a culture that stresses care, safety and transparency, instead of inciting fear and invoking blame.

Pam Frampton is The Telegram's story editor. She can be reached by e-mail at pframpton@thetelegram.com. Read her columns online at www.thetelegram.com.

Organizations: Wall Street Journal, Outcoming Engineering, The Joint Commission Perspectives

Geographic location: Madison, Wis., Wisconsin

  • 1
  • 2
  • 3
  • 4
  • 5

Thanks for voting!

Top of page

Comments

Comments

Recent comments

  • Polly
    July 02, 2010 - 13:30

    ----Obviously Kennedy couldnt sustain the impressively calm demeanor he displayed during the H1N1 pandemic and hes slipped back into attack-dog mode---- Kennedy , the sly, old dog knows very well that you get more flies with honey ... This government had an agenda with the H1N1 programme , they were looking for positive results , and they were dealing with a frghtened public and everyone knows that when dealing with fear , you need calming reassurance . Pam , I am afraid that just suggesting that, Kennedy and Williams change a toxic environment, isn`t enough . They have already seen what works for them and their attitude just maybe , if it ain`t broke , why fix it . And yet again, an article worthy of praise .

  • Polly
    July 01, 2010 - 20:17

    ----Obviously Kennedy couldnt sustain the impressively calm demeanor he displayed during the H1N1 pandemic and hes slipped back into attack-dog mode---- Kennedy , the sly, old dog knows very well that you get more flies with honey ... This government had an agenda with the H1N1 programme , they were looking for positive results , and they were dealing with a frghtened public and everyone knows that when dealing with fear , you need calming reassurance . Pam , I am afraid that just suggesting that, Kennedy and Williams change a toxic environment, isn`t enough . They have already seen what works for them and their attitude just maybe , if it ain`t broke , why fix it . And yet again, an article worthy of praise .