0:00

So talking about mistakes in the organizational culture,

0:03

I wanna highlight the just culture, uh, model.

0:07

And, uh, that's trying to balance blamelessness

0:10

with some accountability

0:11

because sometimes people do things that really aren't

0:13

so good, and we need to have some degree of accountability.

0:16

Everything isn't blameless,

0:17

but most of the errors that we make are,

0:20

and you don't wanna punish people

0:21

for making good faith errors.

0:23

Um, you want, you want errors

0:26

and near misses to come to light

0:27

so they can be analyzed so we can learn from them.

0:30

So we can fix our system.

0:32

You wanna have good error detection and classification

0:34

and analysis, and you can't have those if people are hiding

0:37

their errors because they're afraid of being punished.

0:40

And also, since most errors are good faith,

0:43

we wanna have compassion for ourselves

0:45

and others when good faith errors are detected.

0:48

And, you know, this is really harder than it looks.

0:50

Our culture in medicine is really not all

0:52

that compassionate, uh, toward, uh, uh,

0:55

people when they make errors,

0:56

the assumption is that we will be perfect.

0:58

That we should be perfect, that we must be perfect.

1:01

And, um, you know, it, the, this is very hard.

1:04

This is a, a, a comic from the Wall Street Journal.

1:07

Uh, the, the wife is saying to the husband, you know,

1:10

don't be so hard on yourself.

1:11

Lots of people have been a hundred

1:13

percent wrong about everything.

1:15

Hopefully a medicine.

1:16

We're not a hundred percent wrong about everything,

1:18

but we are gonna make mistakes from time to time,

1:20

and we'd actually like it to be a, a blameless culture.

1:23

But we're not there yet.

1:25

We're still very much swimming with the sharks.

1:27

And this is a typical, uh, way that, uh,

1:29

you know, we handle errors.

1:31

You know, this is the, this is the colleague

1:32

that made an error and this is his section chief

1:35

and these, so, uh, you know, we, we don't want

1:38

to deal with errors that way.

1:40

You need a blameless culture.

1:41

And this is a quote from Lucian

1:43

Lip who is a retired surgeon.

1:44

He was testifying, um, to Congress about medical errors.

1:48

And he said the single greatest impediment

1:49

to error prevention in the medical industry is

1:51

that we punish people for making mistakes.

1:54

And that's why we need that, that blameless culture,

1:57

just culture, um, to, um, make it possible for errors

2:01

to come to light and be studied.