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ADVANCE Perspective: Nurses

Mistakes Were Made

Published June 15, 2010 4:57 PM by Matthew Patton

Wall Street failures. The housing market and mortgage industry collapse. The epic, disastrous BP oil spill. Huge mistakes with dire consequences for a large chunk of the global population. How can "these people" sleep at night after pulling the wool over our eyes? The answer, according to a newly released book, is the wool most likely covers the eyes of the guilty parties as well.

In their book, Mistakes Were Made (But Not By Me): Why We Justify Foolish Beliefs, Bad Decisions, and Hurtful Acts, authors Carol Tavris and Elliot Aronson explain how people dodge responsibility when things start to fall apart. Public figures, for example, seem somehow unable to fess up when they mess up. The authors write that psychologically it's easier to see hypocrisy in others and not ourselves. Have you ever worked with someone who just downright didn't know how to admit they'd made a mistake? It's intriguing to see the "offender" dance around the issue or try to justify the mistake or place blame. It's an interesting phenomenon to notice how people, groups or businesses disassociate themselves from mistakes.

And, yes, it happens in healthcare. One of the most famous examples involves actor Dennis Quaid and the tremendous medical error that put the lives of his twins at risk. In an interview, Quaid recounted a call he made to nurses to check in on the babies. He was assured they were fine. In reality, they had been given an overdose of heparin to flush their IVs. Quaid said nurses knew of this when he called; however, he and his wife were not made aware of the mistake until the next morning when they reached the hospital. By then, it was a life-or-death situation. Throughout this case, fingers were pointed at the hospital's pharmacists, physicians and nurses, as well as the pharmaceutical company that manufactured the heparin. Quaid claims no one has admitted to this mistake (he continues to advocate for higher standards of medical safety since the 2008 incident).

Why, then, has no one fallen on the sword? One reason is cognitive dissonance is involved when mistakes are made. And, the authors of the book argue, dissonance is hardwired. Perhaps the healthcare professionals caring for the Quaid babies could not fathom their role in such an incomprehensible mistake; there's no way they read the label wrong or picked up the wrong vial. It must have been labeled incorrectly. Perhaps the thought of being held responsible was unthinkable. It just couldn't be their mistake.

In light of the recent mistakes cropping up in the headlines, do you think we can learn from our mistakes? Probably not. As humans, we tend to treat mistakes like hot potatoes, passing them from person to person, eager to rid ourselves of them and throwing them on someone else's lap.
But wouldn't it be nice if someone would step forward right after a mistake is made and take accountability? "I was responsible for this and I'm sorry; now, how can we fix it?" Maybe then, that same mistake won't happen again.

Matthew T. Patton is editor of ADVANCE for Medical Laboratory Professionals.

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