Gut Check | Friday, December 27, 2019
Education Is Not Always the Answer
When mistakes and errors occur in our organizations, it is our obligation to analyze these problems and assess the reason(s) they occurred. These problems have many different names: sentinel events, incident reports, near misses. When these situations occur, we often form a group to analyze them. We put together a taskforce or committee to examine the situation, discuss it, fishbone diagram the reasons why it occurred, and so on. The most common end product of these taskforces and committees is some kind of mandatory competency module that everyone has to do.
We believe that this is a safe choice and we frequently say, “Education can’t hurt.” To this statement I say, “I beg to differ.” I do not believe that these house-wide mandates are benign interventions that can do no harm. I think they can do harm. I have seen many groups actually create greater problems by overusing educational/competency interventions for sentinel events or incidents that occur. When you choose an educational intervention, you are sending a message to the staff that they are not smart enough.
This can be very dangerous. If one person makes a mistake and you re-educate everyone to prevent this mistake from occurring again, you send a message that all the staff are not smart enough. If you are one of the people trying to do your best every day, follow the policies, and have good outcomes, but time and time again you are forced to be re-trained, eventually these actions can stop you from trying. This can result in a mediocre team. Individuals may start to say, “Why do I even try if my work is so invisible?” And then some of our best employees become disengaged.
So, in some instances, education or competency assessment as an intervention to sentinel events can cause harm. Use this intervention very carefully. Only use it when it is absolutely necessary and when there is a clear assessment that a lack of knowledge or skill was the reason for the error. If you do choose education or competency assessment as a response, make sure it is focused where it is needed. Do not just “spray and Pray,” meaning spray it on everyone and pray that it improves outcomes.