Friday, December 4, 2009

In patient safety, there is a spoken and unspoken “rule” that we are not supposed to blame the people who make errors. There is a system, in most cases that causes these errors to occur. This is known as the Swiss cheese model. This term is used regularly to explain how errors happen.

Because there is usually a system break down, where the error is not caught, if it makes it through the holes in the Swiss cheese, it is not just one persons fault. Therefore, we couldn’t possibly punish (suspend or fire) an employee who causes harm to a patient.

On my way back from the airport, following a 1 ½ day patient safety meeting, I was surprised to hear on the radio that the Secret Service agents who allowed a couple to crash President Obama's first state dinner were suspended.

In the newspaper today I read that Secret Service Director Mark Sullivan said it was “human error," which allowed these unknowns to intrude. For this, three men were suspended.

Although I am not advocating firing or suspending someone who makes an error, I’m just wondering why I am seeing this as a bit controversial. Care to comment? Please do.

1 comment:

Anonymous said...

You need you to make up your mind.Say what you mean. Do you represent the injured patient or the medical professionals that make up the system? Is it too scary to insist that accountability has a place in the repsectful resolution of iatrogenic injury when your income comes from the system itself trying to avoid its own responsibility for its shortcomings?