I'll get you, my pretty!

This post is a follow-up to my previous post Witch Hunts in the Hospital. This morning I listened to an audio program from the Institute for Healthcare Improvement's Open School for Health Professions; it is called "What is it like to be trapped in an error?" and you can download the audio or a transcript here. The IHI's ideas are new to me (admit mistakes? encourage openness about mistakes? mistakes are GOING to happen? medical errors involve TWO victims---the patient and the provider?) and extremely eye opening. The entire thing rang true to me and lit a fire under me to wave the banner of stopping hospital witch hunts. Currently, I rarely learn from other folks' mistakes because everything is hushed up. No one learns from mine because as soon as the error is discovered it is hushed up. I've committed only one BAD error, but I don't even have my license yet. I live in constant dread of the next one. I felt a little vindicated to hear the program mentioned above, because it emphasizes the systemic and human-related aspects of errors. I had no idea that there was actually a science of investigating and preventing health care errors. It is helpful to feel that a framework exists to help combat that constant fear of making a bad mistake.

In addition, I was gloomily happy to hear that other people, too, are horrified by their errors. The other people involved in "my" error appeared to blow it off, and outsiders who got the HIPAA-fied version of the story unilaterally said, "Learn from it and move on." I was really upset: when I got home from work that day, I sat under a hot shower and cried for a long time, and after that I went to bed feeling that I was unsafe as a patient-care provider and had made a horrible choice for a career. I felt like a freak for being that upset when no one else appeared to be. However, the folks in this audio discussion admitted that they were also very upset when they made bad mistakes (the nurse says she felt like she was going to throw up), and this helps.

It would be so much easier to navigate errors and use them to improve patient care if we could somehow promote openness, remove punitive witch hunts and gossip, and be honest with each other. My one incident occurred a while back, and still no one has asked me a single question about what happened. I even went to my boss recently to volunteer the information because there are elements about it that could be easily used to prevent a repeat, and she didn't want to discuss it. It's just weird.

Anyone have any comments on this? Is this a top-down or bottom-up change? How can we start? What can one nurse do? Redoubling our efforts is good but ultimately leads to exhaustion. I don't think it's enough.