Anatomy of Errors: My Patient Story

Patient Safety Through My Eyes

In a recent article published by MGMA, Barb Davis, SVP of Clinical Services at CipherHealth, shares the different types of errors using the Science of Safety Framework, integrating her own patient experiences as a symptom of broader system-level issues to highlight how health systems can provide a safety net for their patients with outreach.

According to Dr. James Reason, the grandfather of safety literature and error categorization, there are two categories of error – person and system. Errors are the consequence, not the cause, of designs upstream from the actual error itself. Put simply, human errors are inevitable and occur in large part due to poorly designed systems.

Davis discusses how in healthcare, as in many industries, we tend to focus on a person approach and the unsafe acts – errors and procedural violations – of people on the front line. Instead of examining the contributions of the system, we fault the individual by attributing unsafe acts to mental processes, such as forgetfulness, poor motivation, carelessness, and perhaps negligence. In response, we write a new procedure, post a new poster, or name/blame and shame an employee or staff member. In fact, we should address errors with a systems approach, which accepts that errors will occur and puts safeguards in place to prevent them. We should all aim for continuous reform, rather than local fixes. This continuous striving for system reform is the product of safety work: it is the organizational culture and underlying values.

Read the full article to learn from Davis’ analysis of her own patient experience through a safety lens.

Barb Davis

Barbara Davis, MA has been involved in quality in healthcare for over 30 years, and currently serves as CipherHealth's SVP of Clinical Services. She has worked in complex health care environments, including a university health system, an HMO health plan, and multi-hospital system. Her areas of expertise include quality improvement and Lean, service excellence focusing on organizational culture and the patient experience, patient safety and reliability, regulatory issues and organizational strategic goal setting. Currently she sits on the Patient and Family Advisory Council at Saint Joseph Hospital in Denver.