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Opinion |
1 Department of Radiology, Indiana University School of Medicine, 702 N Barnhill
Dr., Rm. 1053, Indianapolis, IN 46202.
2 Indiana University School of Medicine, Indianapolis, IN 46202.
Received August 3, 2006;
accepted after revision August 18, 2006.
Address correspondence to R. B. Gunderman
(rbgunder{at}iupui.edu).
Keywords: education • error • radiology practice
Knowledge rests not on truth alone, but also on error.—Carl Jung
For radiology organizations to succeed, we must become more adept at learning from our experiences, especially from our errors. It is certainly more gratifying to succeed than to fail, but it is from mistakes that we stand to learn the most [1]. Learning from errors requires a kind of education different from the one most of us received in medical school and residency. It is not memorizing the answer to a question, solving a problem, or developing proficiency at a new technical skill. Instead, education involves critically inspecting our own practice and the systems we use and improving these systems when errors arise.
The importance of this kind of learning is reflected in the fact that practice-based learning and improvement have been established as one of six general medical competencies by the Accreditation Council for Graduate Medical Education (ACGME) Outcome Project, rendering these competencies integral to the missions of all accredited residency and fellowship programs [2]. In essence, we need to be more reflective and even skeptical about the way we are currently doing things and to think creatively about ways we could do them better. Organizations that fail to learn from and improve their practice will stagnate and eventually become extinct [3].
Despite the undeniable importance of learning from error, many radiologists and radiology organizations know less than we should about this important topic. To enhance our understanding and performance, we need to do three things. First, we need to make a commitment to raising our level of performance. As long as we regard the status quo as sufficient, we are unlikely to achieve something better [4].
Second, we need to see errors as opportunities for improvement. Errors are not diseases but symptoms of flawed underlying structures and processes that we are capable of improving [5]. It is not the occurrence of error that is damning but the failure to seize on it as an opportunity for improvement. When we see them as opportunities, errors cease to be something to hide and become resources that we want to visualize and even highlight.
Third, we need to recognize the barriers to openness about error that bedevil many radiology organizations. By identifying and deepening our understanding of these barriers, we can enhance our ability to learn from error and thereby raise our level of performance [6].
One barrier to openness about error is the sense of shame we tend to feel when our errors are seen by others [7]. By nature, most physicians like to be right. Even more so, many of us hate to be wrong. Recognizing, acknowledging, and exploring error are hampered by our fear that if others see our mistakes, they will think less of us. Patients may go elsewhere for care. Referring physicians may send their patients to other physicians or facilities. Our colleagues may pass over us in decisions about hiring, promotion, and tenure. If others see us as error prone or even merely fallible, we mistakenly suppose, we will never achieve the level of respect to which we aspire.
This feeling of shame is one of the most corrosive attitudes that besets organizations striving to enhance their commitment to excellence. Shame leads us to keep mistakes under wraps. We begin by hiding our mistakes from others. Eventually, we become so error averse that we may inadvertently hide our errors from ourselves [8]. In so doing we deprive ourselves and our organizations of one of the most valuable resources in the quest for improvement. We become so wrapped up in preserving the illusion of our infallibility that we no longer respect the significance of our mistakes, and we forgo the opportunity for improvement mistakes represent. In effect, we allow pride to dominate our curiosity and appetite for excellence.
The best justification for pride in our work is not infallibility. It is a deep commitment to learning. To create a culture that is genuinely committed to learning, we need to inspire a sense of optimism and trust. We need to convince ourselves and others that mistakes are not lethal and that we can not only survive them but also grow from them. Moreover, we need to show everyone that errors will be treated not as occasions for mean-spiritedness and invective but as opportunities to enhance everyone's work. When we see mistakes as symptoms of more fundamental problems, we can place less emphasis on who made them and focus more on what they tell us about our organizational systems [9]. For example, an error traceable to a breakdown in communication may tell us less about the communicators themselves than about the systems through which we share our knowledge, perspectives, and experiences [10].
If the search for scapegoats is so counter-productive, why is it so popular? The blame game is attractive for a number of reasons. First, our system of medical education tends to foster the view that every error is traceable to an individual. Throughout our training, every examination we take has right and wrong answers. We see incorrect answers as the fault of the student taking the examination, not the fault of the educational system.
Second, our legal system, in particular the recent growth of a health care culture deeply pre-occupied by malpractice, fosters the view that every adverse outcome stems from negligence. If everyone were doing his or her job properly, we seem to suppose, how could errors occur?
Third, finding someone to blame gives us an outlet for the built-up tension, guilt, and even anger often associated with error. By heaping blame on someone else, we believe we can lighten our own loads. Blame is hazardous and punishment is toxic because they drive errors deep underground, where they cannot be seen and learned from [6].
Most of us are attracted to the ideals of autonomy and independence. It is comforting to believe that everything depends on our dedication and expertise. This belief implies that when things go well, all credit is due to us. We like to see ourselves as key people without whom our organizations could not function. However gratifying such fancies may prove at a personal level, by their very nature they tend to undermine a culture of information sharing and collective learning.
Instead of focusing exclusively on the decisions of individual practitioners, we can do better for our organizations and the patients and communities we serve by attempting to define patterns of practice conducive to collective excellence. Health care is less an individual sport than a team sport, and we need to focus more on the long-term performance of organizations and less on the short-term performance of individuals. In many if not all cases, the root of error lies not in the individual but in the system [11]. To reduce errors and improve performance, we must spend less time looking for individuals to blame and start looking at our systems and how they need to change.
What can we do to mitigate the sense of shame that tends to inhibit the open exploration of error? First, by promoting a culture in which learning from errors is highly prized, we can eliminate the irrational but debilitating fear that we are the only ones making mistakes [6]. Everyone makes mistakes. That anyone greets this assertion with incredulity only reveals that we are operating in an environment where errors are suppressed [3].
Second, we need to make it clear that recognizing and sharing errors will not meet with reprisal. This concept is particularly important when the mistakes in question are being made by people in positions of authority. Leaders can make a great contribution to building a learning culture by serving as good role models in being open and honest about their own errors [8].
Another barrier to learning from errors is the wide dispersion of responsibility throughout an organization. If it is not clear who is responsible for different organizational missions, it becomes too easy simply to blame others when things go wrong and even to leave to others the responsibility for noticing errors in the first place [12]. Every radiology organization should clearly define who is responsible for detecting errors and investigating them. Likewise, it is important to define who is responsible for anticipating errors and preventing them. In a first-rate organization, everyone is involved in learning, but different people are responsible for different domains, with go-to people for each facet of the organization's strategy and operations.
Being open about errors makes sense only if the organization is truly committed to doing something about them. Such commitment means developing and improving systems for detecting, sharing, and responding to errors [6]. Simply maintaining a list of things that have gone wrong offers little opportunity for making things better. What procedures are in place for identifying risk? What avenues are available for sharing lessons learned? Who is accountable for ensuring that changes are made? Do people ever meet to discuss the answers to these questions? Are such opportunities regular items on meeting agendas, and do people genuinely prize the opportunity to learn from one another? If nothing ever gets done in these areas, people will soon lose both their faith in the process and the courage and openness essential to a true learning organization [4].
Underlying the need for openness about error is an important truth about social life. On one hand, an organization made up of different specialists can achieve outcomes that lie beyond the reach of individual generalists. This is the great principle of division of labor. It is not difficult to imagine the problems that would beset a radiology department in which radiologists were required to perform the functions of receptionists, nurses, technologists, patient transporters, and so on. On the other hand, the more specialized we become, the greater is the danger that we fail to understand one another's work [8]. We need to depend on one another, but we also need to develop systems to improve the quality of our collaboration.
We can devise all manner of professional, civil, and even criminal penalties to discourage mistakes. We can implement any number of financial, professional, and social rewards for those who avoid them. What we really need, however, is a paradigm shift in the way we think about error. Once the profession of medicine operated in a paradigm dominated by bloodletting, and as long as it did, our therapeutic results remained deeply constrained. As long as we continue to operate with a paradigm in which error is regarded as a disease that afflicts individuals, our organizations' levels of excellence will be constrained. We need a paradigm shift in the way we think about error, a paradigm shift that begins in building a culture that recognizes errors as valuable learning opportunities [7].
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