Have you ever noticed that the persistent problems affecting our patients today are the self-same problems that we were facing 20 years ago? Back in 1999, To Err is Human was published by the Institute of Medicine (now the National Academy of Medicine) to raise awareness about the devastating breadth and severity of harm to patients who received healthcare services. Today, the rate of patient falls and infections is largely unhindered, with many experiencing an increase in rates during these post-pandemic years.
And our big solutions are often the same:
- Ask for volunteers to create an acronym
- Tell the clinical managers to harass staff until the issue gets better temporarily
- Capture the data on that temporary improvement
- Publish the results as groundbreaking (and then we can all breathe easy and let it slide)
I recently heard a lecture on Post-Traumatic Stress Disorder (PTSD) where the clinician shared how PTSD typically does not develop from violent harm alone -- it is when there is a sense of malevolence, or evil, that it becomes deeply rooted in our psyches.[1] So it’s no wonder that clinical staff are experiencing burnout and PTSD as we repeat the same preventable mistakes -- there are times when it feels malevolent to allow the same terrible things to happen over and over again to our patients.
My proposal today is a radical shift towards internal transparency. I often saw ads for volunteer Lunch & Learn sessions offered at hospitals across the nation to support the continuing education of nurses. Unfortunately, unless the hospital boasted novel research with free lunch and continuing education credits, it was unlikely to be well-attended by exhausted nurses on their own time. I also witnessed town hall sessions where staff questions were silenced or retaliated against by managers. Sometimes it seems nearly impossible for nursing staff to share improvement ideas or question policy, but we are surprised to find that the same mistakes are still happening. Hmm.
By Gayle Porter
