Why it is critical we learn from past health care mistakes

Forty is the new thirty. Orange is the new black. And failure is the new success.

It seems these days that no success story is complete without a failure (or two) along the way: the bankruptcy that gave birth to a successful company; the entrepreneur who lost it all just before hitting the Fortune 500. Entire issues of the Harvard Business Review and the New York Times Magazine have been devoted to failure. In the business world, leaders are often told: “Fail fast, fail early, fail often.”

In many sectors it is understood that to innovate, we must accept — even celebrate — failure.

Health care needs positive innovation. At nearly 12 percent of our GDP, health care is a huge part of the Canadian economy, and one in which new ways of doing business are needed — yet it is an industry that has not accepted that part of improvement must be a willingness to fail.

Thus when we fail in health care, we often double-fail: once in the event and again when we are unable to recognize, name and learn from that failure.

In health care, where lives are on the line, failing early and often understandably sounds unpalatable. But of course we do fail in health care. And while we don’t want to encourage failure, we do need to shift away from a culture that can’t acknowledge failure towards one where it is understood to be part of the process of improvement.

Failures in health care occur at two levels: the level of the individual patient and the system level. It is often easy to recognize failures at the patient level. These are when medications get mixed up, unnecessary infections occur, or poor communication leads to harm. We are getting better at communicating failure at the provider-patient level. Organizations are adopting policies and approaches that facilitate sharing — moving away from “blame-and-shame” cultures in order to improve.

However, learning within a single organization is not enough when there are thousands of organizations that make up our health system. Right now, we have limited means to facilitate learning from each others’ failures across organizations. This is particularly worrisome in an industry where similar environments and sets of interactions repeat themselves. An ambiguously labeled vial that leads to medication error in one long-term  care home will be identical to vials in hundreds of other homes. A cleaning process susceptible to human error used in one operating room will be used in dozens of other operating rooms the same day.

System level failures in health care happen but are harder to see.

In a public health care system, too often system failures end up as fodder for Question Period battles rather than impetus for learning. When investments have been made in new models of health service funding and delivery that don’t work out, it can be difficult to proclaim failure as a means to move toward success. But in the absence of a willingness to be open about policy ideas that didn’t pan out, we risk continuing to invest in sub-par models of care delivery and we hinder our ability to achieve excellence as a system.

Patients and the public are part of the answer.

We all put tremendous faith in the health care system at times of incredible vulnerability. Patients and families want to trust in our system; they need to believe that when the stakes are so high, it will work. But providers and organizations also need to trust patients and the public that they will not only understand our failings but help us do better.

The best way to honor a person who has been harmed by a health care failure is to do everything possible to learn from that failure so that it will not be repeated.

Solutions are not easy. Some can be learned from other industries, some will be health care specific. We need structures and processes so learning can occur across the system. We need the health education system to prepare providers for a career learning from, and not burying, failure.

Failures must become teachable moments, not professional risks.

In an industry as large and complex as health care, where innovation is a must, we are bound to make errors. But it’s the double-failure that we should worry about: the inability to name and learn from our failures so that we can do better.

Joshua Tepper and Danielle Martin are family physicians in Canada. They are both expert advisors, Evidence Network.

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