Like so many of you, I was really worn out by the time the World Series ended. What an exciting series for Houston Astros fans! Whether you are a fan or not, after Hurricane Harvey, the championship gave Houston something to cheer about, and I think for many, it was a much needed boost.
Watching the series, I was reminded of the story of Armando Galarraga, a pitcher for the Detroit Tigers. On June 2, 2010, he was only one pitch away from a perfect game. With one more out to go, his name would be etched in baseball history as having pitched the 21st perfect game. However, the batter hit a ground ball to the infield, and in a close call, he reached first base just as the first baseman caught the ball. The umpire ruled the player was safe. That call ruined Galarraga‘s potential for a perfect game, perhaps the only one he would see in his career.
The umpire, Jim Joyce, believed that he had made the right call until he saw a replay after the game. From all angles, the replays showed that the runner was, in fact, out. Mr. Joyce’s call was incorrect. Emotional over his mistake, Joyce went out to see Galarraga and apologize for the incorrect call. He admitted his error. While Galarraga could have been ungracious in his response, he quickly accepted the apology and even gave Jim Joyce a hug. Later, Galarraga was quoted as saying, “He really feels bad – probably more bad [sic] than me.” The apology took courage; Galarraga’s acceptance took grace.
Wow, what a wonderful story!
Joyce’s apology epitomized accountability at its height – take responsibility for your mistakes. Even though it isn’t always easy and it sometimes takes courage, when we get something wrong, we should admit our error. It is the right thing to do. When we demonstrate accountability in this way, it often creates a relationship of trust with others. In turn, this generates respect.
There are different ways of thinking about accountability. In the book, “Waiting for the Mountain to Move,” the author, Charles Handy, talks about two types of accountability. The first type is the easiest to identify and reflects Joyce’s actions. The second type is arguably the more important of the two – it occurs when we see an opportunity to do the right thing, but we fail to act.
In many respects, we need both kinds of accountability at work. When it comes to error reporting in health care, for example, both types of accountability are definitely important. The most effective approach is to always report when something has gone wrong or had the potential to go wrong. At UTMB, we currently utilize our Patient Safety Net (PSN) system to document these safety events. Once a report is submitted, it is then reviewed in our Quality & Safety Department and assigned a risk rating of 1 to 10. Then, the error is explored in the context of the operational system, and we make recommendations for improving our processes so we will avoid similar types of errors in the future.
An example of the first type of accountability error in terms of event reporting would be an instance in which a nurse, after scanning the patient’s identification bracelet, their employee badge and the bar code on the medication, discovered that they had the incorrect medication for the patient. At that point, the nurse would stop the medication administration process. No harm has come to the patient, but there was a mistake in either entering the dose of medication or in filling the medication for delivery to the patient. Thanks to the three-step process, it was caught before there was any harm to the patient. Unfortunately, the reality is that not all errors are caught, and in rare instances, a patient can potentially be harmed. This is why in addition to following the processes that are in place to help prevent errors, our careful attention is crucial.
An example of the second type of accountability, and another way we use the patient safety event reporting system, is when “near misses” are reported. Near misses are instances in which an employee sees a process with the potential to cause harm, but they are able to speak up and prevent the error. By reporting the event, the quality and safety team can review and amend the process BEFORE any harm ever comes to a patient.
When I was in Wisconsin, we had a team that reviewed all of the submitted patient safety event reports, just as we do at UTMB. One report, in particular, was completed by a nurse who stated that the new tubing for administration of IV solutions and drugs seemed to be crimping. This meant the patient wasn’t always receiving the IV at the rate prescribed. Once she noticed this was occurring with several of her patients during a shift, she reported her observation. Once the quality department began reviewing her concern, they discovered that, indeed, there was a problem. At that point, the team set out to identify a new vendor and replace the tubing to eliminate the potential for patient harm. Because of this very observant nurse AND the fact that she took action, no patients were ever harmed.
Some of you may ask, “Well, what if I report something and nothing is wrong? Will this reflect poorly on me?” The quick answer is "no, not at all." In fact, we would rather review a report that may not culminate in the need to change practice, supplies or equipment than to not have a concern reported at all. It is only through careful observation of our systems and processes that we can move closer to our goal of “zero harm to patients.”
It is a quote I have referenced before, but it is one worth remembering: Paul Hawken once said, “You can blame people who knock things over in the dark, or you can begin to light candles. You’re only at fault if you know about a problem but choose to do nothing.” Speaking up when we make a mistake, see a problem or identify an opportunity to do the right thing means that we are truly demonstrating accountability.