[Patient safety 4.0: "Failure of the Week" It's all about role modelling!].

Ulmer, Francis; Krings, Rabea; Häberli, Christoph; Bally, Romina; Schuchmann, Marcus; Huwendiek, Sören; Kabitz, Hans-Joachim (2023). [Patient safety 4.0: "Failure of the Week" It's all about role modelling!]. Deutsche medizinische Wochenschrift, 148(15), e87-e97. Thieme 10.1055/a-2061-1554

[img]
Preview
Text
a-2061-1554.pdf - Published Version
Available under License Creative Commons: Attribution-Noncommercial-No Derivative Works (CC-BY-NC-ND).

Download (2MB) | Preview

BACKGROUND

The rate of mistakes and near misses in clinical medicine remains staggering. The tendency to cover up mistakes is rampant in "name-blame-shame" cultures. The need for safe forums where mistakes can be openly discussed in the interest of patient safety is evident. Following a comprehensive review of the literature, a semi-structured weekly conference, named "mistake of the week" (MOTW), was introduced, enabling physicians to voluntarily discuss their mistakes and near-misses. The MOTW is intended to encourage cultural change in how physicians approach, process, accept and learn from their own and their peers' mistakes. This study seeks to assess if physicians appreciate, benefit from and are motivated to participate in MOTW.

METHODS

Physicians and medical students of the I. and II. Medizinische Klinik at the Academic Teaching Hospital Klinikum Konstanz (Germany) were eligible to participate voluntarily. Four groups of physicians (n=3-6) and one group of medical students (n=5) volunteered to participate in focus group interviews, which were videotaped, transcribed and analyzed.

RESULTS

The following success factors are crucial for dealing with and voluntarily disclosing mistakes and near-misses: 1. Exemplification ("follow the boss's lead"), 2. Fixed time slots and a clear forum, 3. Reporting mistakes without fear of penalty or punishment, 4. A trusting working atmosphere. The key effects of the MOTW approach are: 1. People report their mistakes more, 2. Relief, 3. Psychological safety, 4. Lessons learned/errors (potentially) reduced.

DISCUSSION

The MOTW conference models an ideal forum to mitigate hierarchy and promote a sustainable organizational dynamic in which mistakes and near misses can be discussed in an environment free from "name-blame-shame", with the ultimate goal of potentially improving patient care and safety.

Item Type:

Journal Article (Original Article)

Division/Institute:

04 Faculty of Medicine > Department of Gynaecology, Paediatrics and Endocrinology (DFKE) > Clinic of Paediatric Medicine
04 Faculty of Medicine > Department of Gynaecology, Paediatrics and Endocrinology (DFKE) > Clinic of Paediatric Medicine > Paediatric Intensive Care
04 Faculty of Medicine > Medical Education > Institute for Medical Education
04 Faculty of Medicine > Medical Education > Institute for Medical Education > Assessment and Evaluation Unit (AAE)

UniBE Contributor:

Ulmer, Francis, Krings, Rabea, Bally, Romina Lara, Huwendiek, Sören

Subjects:

300 Social sciences, sociology & anthropology > 370 Education
600 Technology > 610 Medicine & health

ISSN:

1439-4413

Publisher:

Thieme

Language:

German

Submitter:

Pubmed Import

Date Deposited:

13 Jun 2023 10:01

Last Modified:

28 May 2024 14:05

Publisher DOI:

10.1055/a-2061-1554

PubMed ID:

37308082

BORIS DOI:

10.48350/183364

URI:

https://boris.unibe.ch/id/eprint/183364

Actions (login required)

Edit item Edit item
Provide Feedback