May 22, 2020 | Marcus Miller

Criminalization of Mistakes, It Continues

What to make of the recent incidents where people were disciplined or had actual criminal charges brought against them after an accident?

Last week, Pennsylvania Attorney General, Josh Shapiro, announced a physician was arrested and charged for the 2018 death of a patient.  The patient overdosed on drugs prescribed by that physician.

The Attorney General put out this statement to the press:

“The defendant was trusted by his community to use his position as a physician to save lives, but instead, he stands charged for prescribing his patient a fatal cocktail of drugs despite knowing of and enabling her history of drug abuse,” said Shapiro. “Communities across Pennsylvania are being ravaged by the opioid crisis that is being fueled by people like Dr. Green. My Office will continue to hold individuals accountable who recklessly put the lives of others at risk for profit, wherever those individuals are found.”

Remember, the Attorney General of Pennsylvania is an elected position

And, the next election is right around the corner. Pair that with the fact that these charges come two years after the patient’s death. It seems to me like there may be an alternative motive. But that is speculation on my part. What I DO know is that putting 100% of the blame on this physician will NOT prevent other overdoses and deaths.

It will actually make investigations harder leading to more deaths

Who will willingly help during investigations if they know jail time is on the table? Do you think information critical for effective root cause analysis will be uncovered if attorneys are involved? Do you think the focus of the investigation will remain on uncovering truths for all parties involved, or will some parties be more concerned with hiding evidence?

Listen to my remarks from the 2020 Global TapRooT® Summit regarding criminalization and discipline in this video.

You can glean more examples of criminalizing mistakes and using punishment as a response to mistakes in this brief blog post by Mark Paradies, Will Making Criminals of Executives Stop Accidents?

The purpose of any investigation is to prevent the incident from repeating

Eliminating bias and blame from your investigations is of the utmost importance. When you introduce bias and blame into your investigation, your entire investigation loses credibility and all your findings are open to dispute and second-guessing. Instead of blaming and punishing healthcare workers, we should be asking them about what failed. Where were the opportunities to recognize the dangers for a patient and to respond appropriately to decrease risk? If there wasn’t a way to detect the problems and alert the right people who have a standard, proven process to follow for a response, then there is little hope to correct the problems before something bad happens.

TapRooT® standardizes your RCA process with a simple, easy-to-use framework that eliminates bias and blame

The TapRooT® methodology is based on human factor and equipment reliability expertise, so no matter who conducts the RCA, the results will be consistent and reliable, just as if a human performance expert did the RCA. When you have TapRooT® training, you also have the confidence and expertise to find and fix problems, conduct investigations, and mitigate/eliminate precursors and incidents going forward.

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In the meantime, stay safe and healthy.


Accidents, Courses & Training, Human Performance, Root Cause Analysis
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