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Applauding Organizational Bravery

May 22, 2015
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No one wants to admit they screwed up. 
As a journalist, where you ask people questions for a living, it's not uncommon to have them tell you about the 100 right things they've done and avoid the one wrong thing they "didn't" do.
When I was a kid, my dad was my team's soccer coach. While some fathers may favor their children, mine was not that type. Any screw ups I had on the field, of which there were many, would get amplified in the car ride back with FBI-like questioning. "What were you thinking on that play," he'd ask. I'd always get defensive. "What about this, that, and other. I did that right and you don't want to give me any credit," I'd tell him. 
It's much harder to raise your hand, admit you made a mistake, and talk about it when someone is asking you about said mistake. It's human nature. 
In healthcare, screw-ups do not go easily into the night. A screw up from a practitioner can cost a patient their life. A data breach can ruin a patient's life. After a large screw-up, most hospitals and health systems have large multi-department meetings to break down what happened.
I guess that's why so many try to "plead the fifth" when we ask them about screw-ups. They've already talked it over with so many hierarchal levels at their organization and stewed over it internally, why should they tell someone who is going to publish their mistake for everyone to see? (Not to mention, executives' fear of legal repercussions). I get it. I've been stonewalled by plenty of people for that reason and I never take offense. 
On the other hand, that's why I find it all the more impressive when someone is willing to talk openly about their mistakes. For instance, the University of California at San Francisco (UCSF) Medical Center deserves a lot of credit. UCSF is one of the most renowned healthcare organizations in the country, especially from a technology and innovation standpoint. As we know though, even the best organizations are prone to making a vital error or two. 
A little while back, UCSF did just that. A nurse administered a 38-fold overdose of a drug called Septra, thanks to issues with alert fatigue, an unsure practitioner, and a series of "Swiss cheese" factors. The overdose nearly killed a young, teenage patient. 
A lot of organizational leaders would have hidden that kind of mistake close to the vest. They would have pleaded ignorance and pretended those sorts of issues didn't happen at their hospital. 
UCSF not only talked about it, but they let Robert Wachter, M.D., a professor and the associate chair of the Department of Medicine at UCSF, write four chapters in a book about the incident. Dr. Wachter featured the tale in his book, Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine's Computer Age.
Wachter, who I recently interviewed for a two-part series, talked with me about his organization's willingness to participate in this book, despite the fact the incident makes them look bad. Here's what he had to say:
I think it’s a remarkable act of organizational bravery....There was a lot of bravery. The mother allowed me to interview her and her son. The most the brave people were the doctor, nurse, and pharmacists...they asked me to change their names...I could see them never wanting to talk about it again. They all said, if anyone could learn from this experience and decrease the chances of it happening again, then it's worth doing. I'm proud of them and proud of my organization for letting me doing this. Not a lot places would have.
I couldn't agree more. Healthcare is about improving the lives of people. Admitting you screwed-up, talking about how the screw-up happened and could have been avoided, and teaching those lessons to the masses is part of that improvement process. 
Some organizations, like UCSF and like Beth Israel Deaconness in Boston, get that and have people that are happy to impart that wisdom. Some want to pretend everything is just fine and dandy. 
The lessons from UCSF's mistake are that IT isn't a technology project, and things are not fine and dandy. As Wachter told me, UCSF has the best system money could buy. Even still, the technology has to be engineered with the provider in mind and reduce the threat of automation complacency. The providers are the ones using it. "We spend our $300 million, Epic is put on your computer, and you want to believe you’re done. But you just started," Wachter said. 
It's not an easy lesson to learn, but everyone has to learn it. Of course, mistakes are bound to happen. That's where the brave stand up, raise their hand, and talk about it.
The others? They plead the fifth.
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