TY - JOUR
AU - Gleason, Kristine, M.
AB - When my husband and I decided to become a one-income family to raise our four young children, I was amazed when he requested the job of “stay-at-home dad.” I had mixed emotions about giving up being home with the kids a few days a week and handing over control of most of the household responsibilities, such as cleaning, laundry, maintaining the kid’s schedules, and running errands. My husband slowly transitioned into his new role, and, overall, he seemed to be handling things pretty well. Actually, I even noticed our clothes smelled better than ever, so I had to find out his secret. A scan of the laundry room quickly uncovered a jumbo-sized liquid fabric softener of similar size, shape, and color to the laundry detergent we usually purchased. An emergent meeting with my husband led to the discovery that weeks of dirty laundry had been merely swished in a water and fabric softener concoction. I went into panic mode, swiftly going through my kids’ closets trying to determine the “best-smelling” clothes for rewashing and wondering how he could have let this happen. Then, I stopped and started thinking about my training and role as a pharmacist. Working in quality and patient safety, I have reviewed reports by the Institute for Safe Medication Practices (ISMP) and the United States Pharmacopeia highlighting errors and patient harm due to look-alike or sound alike medication names. I have read numerous published articles describing adverse events due to poorly designed processes and systems that lack fail-safe methods, forcing functions, and resistance to psychological and environmental precursors to error. I have seen processes that rely heavily on memory, vigilance, and the increased training of health care professionals, expecting to consistently achieve desired outcomes with 100% accuracy. My husband’s defense was that the fabric softener looked similar to and was stocked in the same place as the laundry detergent we usually bought. I wondered how this incorrect laundry purchase and substitution might have similarities to hydralazine 25-mg tablets being inadvertently stocked in an automated dispensing cabinet instead of hydroxyzine 25-mg tablets. Would my reaction to the laundry error differ if one of my children developed a severe skin reaction requiring hospitalization or possibly worse? Would this justify my husband being punished for family endangerment, losing custody rights because of this laundry mishap? In his book, Whack-a-Mole: The Price We Pay for Expecting Perfection, author David Marx discusses how we have lost our ability to distinguish among human error, at-risk behavior, and reckless behavior, leading us to expect perfection in our daily lives. He describes human error as an inadvertent action; we have no control over the error or outcome. An at-risk behavior is described as knowingly being noncompliant; the observer and the observed have a difference of opinion and interpretation regarding the behavior and associated tradeoff between risk and reward. Reckless behavior is described as a choice to consciously disregard a substantial and unjustifiable risk. To create a “just culture,” Marx argues that we need to create a widely accepted standard for consoling the human error, coaching the at-risk behavior, and punishing reckless behavior, regardless of the outcome. He also advocates an “open-learning culture,” rewarding individuals for reporting errors so we can learn from mistakes in order to design the safest system while holding each other accountable for the quality of our choices when working within that system. He also expresses concern over instances when human error has been considered a crime, inevitably costing us lives, resources, and lost opportunities to learn and improve as individuals fear repercussions from reporting. To put human error, at-risk behaviors, and reckless behaviors into context and to build the foundation for a just culture, Marx presents numerous scenarios which resulted in adverse outcomes throughout the book. Rather than sharing a few examples to make his point, he presents a wide range of true stories and experiences from sports, health care, aviation, nuclear power, spouses, neighbors, family, and friends in the hopes of ensuring every reader appreciates the widespread nature of human fallibility and the need for cultural change. This book is not about the “how”; it does not provide information on how to design a safer health care system, it does not offer techniques for how to ensure that individuals make better choices, nor does it offer solutions for how to change the current legal environment that often labels and punishes human error as a crime. Rather, this book is about the “why”—why we need a just culture and why it is necessary to distinguish between, and tailor responses and interventions accordingly for human error, at-risk behavior, or reckless behavior to build a safer health care system. Patients and families deserve to know what happened, to know what is being done to ensure an event does not happen again, and to be part of the solution. Health care providers need to be supported if an error is made while working in an imperfect system. Individuals involved in reckless behavior need to be appropriately punished. I highly recommend this book to everyone; it is relevant to health care providers, legislators, policymakers, educators, administrators, professional organizations, licensure boards, patients, and caregivers. We need to reach agreement, acknowledging these types of behaviors and appropriate responses to each, to be able to move forward in developing a just culture and designing and implementing meaningful and sustainable solutions for the safest health care environments. Before serious change can occur, a transformation in our thinking and approach must happen first. This book lays the groundwork for just that. Author notes The Current Literature column features brief reviews of print and electronic publications (e.g., CD-ROMs and software) that are of interest to pharmacists. Reviews of fiction and nonfiction publications loosely related to health care are also included at the editors’ discretion. Readers are encouraged to recommend titles for review by contacting AJHP at 7272 Wisconsin Avenue, Bethesda, MD 20814 (301-664-8601) or ajhp@ashp.org. The author has declared no potential conflicts of interest. Copyright © 2010, American Society of Health-System Pharmacists, Inc. All rights reserved.
TI - Whack-a-Mole: The Price We Pay For Expecting Perfection
JF - American Journal of Health-System Pharmacy
DO - 10.2146/ajhp090495
DA - 2010-02-15
UR - https://www.deepdyve.com/lp/oxford-university-press/whack-a-mole-the-price-we-pay-for-expecting-perfection-JO5caYpP72
SP - 323
VL - 67
IS - 4
DP - DeepDyve
ER -