By Donna Wright, MS, RN, Consultant, Creative Health Care Management
When mistakes and errors occur in our organizations, it is our obligation to analyze these problems and assess the reason(s) why they occurred. These problems have many different names: sentinel events, incident reports, near misses, etc. When these situations (mistakes/errors) occur, we often form a group to analyze them. We put together a taskforce or committee to examine the situation, discuss it, fishbone diagram the reasons why it occurred, and so on. The most common end-product of these taskforces and committees is to come out with two options of actions to implement. These two options are usually an in-service class or a house-wide competency. Both are options that focus on educating people.
It's Easy to Jump to the Conclusion that Education is Needed
These options of education or competency assessment are frequently and easily chosen. We often believe that these are safe choices and frequently say, “Education can’t hurt.” To this statement I say, “I beg to differ.” I believe that in-service programs or house-wide mandatory competencies are not just benign interventions that can do no harm. I have seen many groups actually create greater problems by overusing educational interventions for sentinel events or incidents involving mistakes and errors that result in poor outcomes.
When you choose the option of education as the solution for preventing mistakes and errors, you are sending one of two messages to staff:
1) You do not have enough knowledge or information to do your job.
2) You do not have enough skill or talent to do your job.
Organization-Wide Education Might Convey the Wrong Message Internally
This can be very dangerous. If one person makes a mistake and you reeducate everyone to prevent this mistake from occurring again, you send a message that all the staff are “not smart enough.” If you are one of the people trying to do your best every day, follow the policies, and have good outcomes, but time and time again you are forced to be re-trained, eventually these actions can stop you from trying.
Using “education for all” to address one person’s error may erode self-esteem among your team and create a culture of compliance rather than one of commitment. The result may be a mediocre team.
It’s a simple formula: If an individual succeeds and is not recognized for that effort, and is treated like those who do not succeed, the individual will either stop striving to succeed or leave the organization.
Analyze Carefully to Know Education is the Right Choice
It’s true, of course, that education for all is occasionally the answer. If it is determined that the problem is systemic, then the solution should be systemic as well. But education as an intervention to sentinel events can cause harm and should be used rarely, carefully, and only when there is a clear assessment that a lack of knowledge or skill was the reason for the error.
When you analyze an event, make sure the analysis includes all areas of possible deficit:
1) System problems
2) Tools availability
3) Departmental barriers
4) Communication barriers
5) Attitudinal issues
6) Individual performance patterns
7) Any other barriers that hinder people from taking the right actions
My strong suggestion to every educator and leader in healthcare is to do a full, systematic reflection on the situation before using any education response or intervention in an effort to improve outcomes. It is well worth your time and resources.
Learn more about the leading learning management system in healthcare, the HealthStream Learning Center.
A staff development specialist known for her irreverent wit, Donna brings a global perspective to her work. In this country and in the over two dozen others, Donna’s best known for the work she does based on two of her books, The Ultimate Guide to Competency Assessment and Relationship-Based Care (co-authored with several Creative Health Care Management colleagues). The Ultimate Guide has become the industry standard for HR departments in establishing and assessing competency, and Donna specializes in setting up systems for organizations to ensure accountability and measure competency. Contact Donna at firstname.lastname@example.org.
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