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Penn Medicine @ Work

Human Error: Console Don’t Discipline

When we investigate Safety Net reports,  we usually find one of three behaviors:  (1) Human Error; (2) At-Risk Behavior; or (3) Intentionally Reckless Behavior

In our weekly Just Culture quiz, 40 percent of those who responded to the recent example of a Human Error thought it was At-Risk or Intentionally Reckless Behavior. This means that 40 percent of us might have blamed or punished a colleague for a mistake. Sometimes it is hard to see the difference between a mistake and something risky or reckless.

Human Errors are mistakes, slips, lapses… things we didn’t do on purpose. For example:

... you accidentally order methimazole instead of metronidazole.

... you put supplies away while a colleague is telling you a funny story, and you put the Foley catheters in the wrong supply bin.

... you mistakenly put Patient A’s progress note into Patient B’s chart after a long and tiring shift.

A Just Culture does not punish people for making mistakes like these, no matter what the outcome. We know  we are human; we are prone to certain kinds of errors such as substituting one thing for another or missing a step while being distracted. 

Healthcare in general still has a fairly punitive culture where people are blamed for a human error – sometimes even at PPMC. 

Introducing Penn Primary Care Connection

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Penn Medicine Coding Academy

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Healthy Rewards Challenge Spotlight

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The Patient Service Excellence Academy

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A Partnership in Action The CPUP Patient Service Excellence Academy, a new six-week apprenticeship training program, is dedicated to developing the most understanding and compassionate individuals to work as Patient Service Represen...Full story

Taking the LEAN Road to Better Care

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From Left: Feba Varghese, CRM; Fabian Marechal, Ortho Pract ices; Connie Sumner, Nursing; Chris Melnic, Ortho Resident Vibette Robles, Nursing; Barbara Schrader, Infection Control; Sara Ashley Edwards, Social Work; Finnah Pio, CEQI; Ch...Full story

 

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