My approach to the broad topic of patient safety is informed by core psychological disciplines such as social psychology, learning/memory and personality, organizational theory, and applied cognition. I see patient safety as an emergent property of systems composed of multiple sets of interrelated variables that are changing rapidly and dynamically.
Imagine a computer screen full of random shapes of different colors and sizes, floating around the screen in random patterns. Despite the appearance of chaos, there will be finite moments where, if we stopped time, the shapes have arranged into a larger pattern that is recognizable. Of course, this is not “intentional” or “blameworthy” – the elements arranged in this way only because their random walks happen to coincide at just the right moment. James Reason’s Swiss Cheese model of human error is similar to this notion, save one important difference. Reason argued that errors were latent, resting under the surface of a system, waiting for some unfortunate soul to unwittingly unlock the gates of hell and let them out.
In my view, there is no such thing as error.
Error is a post-event construction used to identify events that did not unfold as intended. “Error” is just a way to talk about these things. Of course, there is nothing wrong with this idea per se, but the word is almost impossible to separate from less helpful notions such as blame, fault, accountability, and carelessness. It certainly should not be surprising that we are quick to find the one to blame where unintended events happen – it is our essential nature combined with a pejorative and loaded word.
My goal is to reduce organizations’ focus on error and enhance focus on safety. Finding errors in my view is a futile pursuit. They are quantum phenomena that materialize and disappear, some wreaking havoc in organizations and most merely being absorbed without a whimper. Our job as patient safety researchers and thinkers is to learn more about how/why individuals act safely. There are many questions that can be asked from this platform:
- How do we think about safety?
- What is risk and how do we define it?
- How do we define it?
- How do we identify “unsafe” situations?
- How do we choose what to do when “un-safety” is detected?
Fortunately, we will not have to reinvent the wheel to answer some of these questions. There is ample evidence in psychology and organizational theory to get us started.
If I can help your organization, hospital, medical facility, pharmacy or any other group with safety from a positive and constructive platform, please contact me to negotiate and customize a way that I can contribute.