From the Ruby Princess disembarkation at the start of the COVID-19 pandemic to the current crisis in aged care facilities, there is no doubt that mistakes have been made by Australian governments at all levels in responding to the COVID-19 pandemic.
In the public and media debate about these issues, the focus can be on identifying the responsible individuals, usually politicians or organisational leaders, and assigning blame. However, experience with other ‘high stakes’ working environments suggests that this is not the best way to improve future decision making.
Below, Dr Mya Cubitt, the Victorian Faculty Chair of the Australasian College for Emergency Medicine, explains why this ‘blame game’ undermines efforts to avoid future mistakes and outlines lessons from the ‘systems thinking’ approach taken by medical and aviation sectors to reducing errors and improving safety.
Mya Cubitt writes:
In a culture of blame, everyone tries to protect themselves, so you can’t get to the truth. In the fight against COVID-19, our politicians can learn from the way we tackle medical error.
Medical errors have high stakes. Wrong diagnoses and treatment errors can, and do, cost lives.
When looking at what has gone wrong, and trying to prevent these painful events happening again, it can be tempting to find ‘the person’ responsible, and punish, blame and shame them.
While this can be emotionally satisfying to those who might demand ‘a culprit’ it doesn’t fix anything. When a culture of blame and shame prevails, it erodes the psychological safety that those working in these high stakes professions must feel.
Lead with acceptance
To address this, we must lead with an acceptance that errors occur due to systems without appropriate checks and balances to prevent or mitigate them, not an individual’s actions or inactions. We all have roles to play in addressing issues as they occur and contributing to system improvements, but blame helps no one.
If every error needs somebody to take the fall, people will hide mistakes, nobody will admit to them and the system will never be fixed. Colleagues will cover for friends, errors will go unreported or hidden. When the finger points at you, you’ll try and point it elsewhere. The ‘blame game’ starts and never really ends.
Sound familiar? So far politicians in Australia have, for the most part, resisted treating the pandemic as ‘politics as normal’ and that is good. Regrettably, there have been recent signs that some see it as their role to engage in blame, shame and point scoring.
For this to continue or escalate would be dangerous in our fight against the virus. If you don’t believe this, then you need only look to our American friends. The blame game certainly isn’t helping over there, and it won’t help here either.
System design and learning
More broadly, those fighting the pandemic must take more lessons from experts in system design and learning.
In the past decades various industries (the medical and airline sectors for example) have learned that the best way to prevent and address error, is to create environments and cultures where people can speak up and are encouraged to share information when things have gone both well and not so well.
Everyone must feel able to share their accounts of adverse events, near misses and good saves without fear of blame and recrimination.
We know that ‘to err is human’, but we cannot redesign humanity. When information on errors is shared and widely analysed, systems, rather than the individuals, can be redesigned. Where errors still occur, the negative consequences can be mitigated and learned from.
A simple example: ACEM knows from its members’ experience and the literature that errors are more likely when emergency departments are overcrowded. With this knowledge we can design the system to stop overcrowding, rather than pointing the fingers at overworked staff in those departments.
Creating a culture
The best way to avoid future error is to use a ‘systems approach’ – to concentrate on the conditions under which individuals work and try to build defences to avert errors or to mitigate their effects – to support the fallible humans within the system.
Effective management of risk, depends on creating a culture that transparently reports data, concerns, errors, near misses and good saves.
We need to take this culture and apply it to the COVID-19 pandemic.
Mistakes have been made at borders, in quarantine management, in residential aged care facilities, in hospitals and other workplaces. No doubt, many more mistakes, in many other settings will be made before we mitigate this pandemic. But now, more than ever, we must learn from these mistakes.
In each case, we must all be able to transparently share the information we have, what we think went wrong, in order to collaboratively work through why, and to explore how to prevent it from occurring again.
A climate of transparency
We need a climate in which this information can be shared and rationally analysed. We also need to look at where things are going right; where is there excellence in the pandemic response that we can learn from?
Most importantly, we must include and share the experience of those at the coal face in the analysis of the adaptations needed, the workarounds applied and the gains subsequently made.
Data and transparency is really, really important at the moment – it is our best chance for defending ourselves from this virus. And for healthcare workers like us, it is a very real, very immediate concern.
We need our politicians to learn from healthcare and lead with a system approach. Bureaucrats fearful of ‘error’ being discovered and politicised might silo data and information.
This will mean that those errors take longer to be identified and fixed. When your problem is a virus as wicked and relentless as this one, blame and holding somebody, anybody, to account is serving no one.
All of our collective efforts are needed to fight this virus, not each other. This virus knows no politics, so let’s put that aside. In this fight for our lives, all of us, our politicians, our media, our communities must collaborate, cooperate and refrain from blame.
Dr Mya Cubitt is the Victorian Faculty Chair of the Australasian College for Emergency Medicine and a Melbourne-based emergency physician.