• Stephen Harden

8 Steps to Take After a Patient Safety Failure

What Everybody Ought to Know About Patient Safety Failures

To err is human.

No matter how well-designed, how well-trained, how easy, how simple, or how intuitive, at some point your...

• Protocol will fail

• Checklist will fail

• Bundle will fail

• Process will fail

• Project will fail

• Initiative will fail

And then harm will reach, or nearly reach, a patient.

Make no mistake. Every safety tool we create and every process we implement to improve patient safety will fail eventually -- if for no other reason than human beings are the ones using them. (Of course, our job is to make sure those failures are extremely rare.)

When failure happens, here’s a protocol for moving forward:

1. Double-check the safety tool (e.g., process, protocol, bundle, or checklist) to make sure that there are no other problems hidden within it.

2. Alert the relevant parties -- the physicians and staff who use the safety tool.

3. Take responsibility for what went wrong. This doesn't mean that you intentionally did it wrong, or that doing it right was solely your responsibility or even part of your job description. It means that you are the one who knows something went wrong, you're unhappy about it, and you accept responsibility for letting it get by you and you are taking responsibility for making sure it won't happen again.

4. Apologize to the team using the tool. Not because it's your fault, but because the failure event costs your staff time or effort or resources or just because it upset them, and you're sorry that they have to deal with that.

5. Come up with a plan to ameliorate the impact of the problem. If you can't come up with a plan, say so and ask for suggestions. There is wisdom in crowds.

6. Develop and implement a plan to avoid the problem in the future. You are not alone in this step. Often, the ones who use the tool know better than anyone else how best to make it better. So, ask for inputs.

7. Gather feedback. Listen with an open mind. Ask the team to justify their recommendations. Assess the input and choose the most promising course of action.

8. Clearly announce who will do what by when to improve the tool. Most everyone forgets this step. Without it, nothing will get done soon enough.

9. Thank everyone for their patience and goodwill. Leave everyone feeling better; help them see excellence in their patient care.

The most effective patient safety failure recoveries come from this protocol or something like it.

Or, you could just hide from the problem, dissemble, blame, shuffle along, scowl, depersonalize, and then move on. But, your patients deserve better from you don’t they?

While we may not be able to prevent all problems, we can learn to recover from them. A good recovery can turn angry, frustrated team members into fiercely loyal ones capable of making patient safety failures extremely rare, and patient care highly reliable.

(Hat tip to Seth Godin for this failure recovery protocol.)


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