"When you invent the ship, you also invent the shipwreck"

The French philosopher Paul Virilio said, "When you invent the ship, you also invent the shipwreck; when you invent the plane you also invent the plane crash; and when you invent electricity, you invent electrocution.  Every technology carries its own negativity, which is invented at the same time as technical progress."  I've been thinking a lot about this quote for the past day or two.  If you haven't heard, RaDonda Vaught, a nurse at Vanderbilt University Medical Center was just convicted of gross neglect and negligent homicide for commiting an error.  

I believe that this verdict will have profound implications on American health care.  I know there are individuals (mostly outside of the health care industry) who would argue that justice has been done, but this verdict and those responsible for it just made our health care system less safe.  It is a well-established fact that reporting mistakes and errors is absolutely critical to learning, improving, and creating safer conditions.  Both the commercial aviation and NASA have drastically improved safety by instituting blame-free reporting of mistakes and errors.  

Near-misses are events in which harm is averted, due to either just plain old luck or active intervention.  They are virtually indistinguishable from adverse events, with the sole exception of the outcome (harm).  As such, they represent golden opportunities to address underlying defects and gaps in critical safety processes.  Experts estimate that near-misses are up to 300 times more common than adverse events in health care, and most adverse events are preceded by a near-miss event.  Unfortunately, near-misses are underreported in health care due to the fear of litigation and/or punishment.  The case of RaDonda Vaught will lead to an even greater reluctance to report mistakes and errors.

W. Edwards Deming, one of the original founders of the quality improvement movement once said, "Eighty-five perscent of the reasons for failure are deficiencies in the systems and process rather than the employee.  The role of management is to change the process rather than badgering individuals to do better."  Deming would be aghast at the recent verdict in the RaDonda Vaught case.  Janie Harvey Garner, the founder of a nursing advocacy group on Facebook called "Show Me Your Stethoscope" said, "Health care just changed forever.  You can no longer trust people to tell the truth because they will be incriminating themselves."

Back to the quote by Paul Virilio.  "When you invent the ship, you also invent the shipwreck."  We have a major problem in health care today - we created a system where people are afraid to come forward and admit when they make a mistake.  The verdict this past week has only made that worse.