Taking the blame out of root cause analysis is critical.  See this article for more information on a physician in the UK who was charged with manslaughter when the system failed her and her patient. Click here.  The physician wasn’t at fault.  She didn’t intentionally make an error.  The system and processes need analyzed and improved so mistakes aren’t made again.  It actually does harm to put a physician in jail because of  process or system errors.  It takes the focus off of the real problems.  It diverts time and resources from where they are truly needed.  It incentives physicians to cover up errors which could be analyzed for lessons learned resulting in better outcomes.  Physician burn out and suicide rates are at an all time high because of the pressure physicians are under. Click here for more info.  They are held accountable and blamed for bad outcomes when something goes wrong.  The responsibility and burden on physicians must be tremendous.  Until Healthcare catches up to other industries that do train their teams on how to conduct unbiased root cause analysis as part of their continuous quality improvement process, the culture will be hard pressed to change.

 

To find more information on TapRooT’s® comprehensive quality improvement process, please contact me at marcus.miller@taproot.com.