Doctor amputated right leg instead of the left.
Patient dies after nurse gives wrong meds.
Doctor operated on wrong side of brain.
You have heard of these horrific incidents.
You have wondered ‘how on earth could this have happened?’ I did too, not as an innocent bystander, but as a hospital executive who was responsible to see to it that these occurrences never took place. In hospital lingo, we called them ‘Sentinel Events.’ They were rare, but when they happened, a team of doctors, nurses and administrators conducted an investigation. The method we used was called ‘root-cause analysis.’ What is at the root of the problem? Is it human error or system error? If human error, deal with the individual; if system error, fix the system. We began by asking the question:
Why did the nurse give the wrong meds to the patient?
Because she misread the prescription?
Why did she mis-read the prescription?
Because she was tired?
Why was she tired?
Because she was overworked?
Why was she overworked?
Because she had done double-shifts?
Why had she done double-shifts?
Because we are short-staffed.
Why are we short-staffed?
Because we have a high turn-over rate in nursing?
Why do we have a high turn-over rate?
Because nurses say that other hospitals are paying higher salaries. When a position opens up, they move.
How much are other hospitals in the city paying nurses?
The series of ‘why’ and ‘why’ stop here. We have the root cause: We underpay, and pay the price with dead patients and grieving families.
Its a system problem. Fix the system. Review the budget and see how we can shift resources to make our salaries competitive; and revise our over-time policy. No back-to-back double shifts.
Why am I bringing this up? Because today when I read this news in the Wall Street Journal, I thought of root-cause analysis. This was the headline:
Pope Francis acknowledges nuns were abused by priests
Let me not talk about how the news made me feel – of nuns getting pregnant, nuns giving birth, sexual slavery; or little boys sexually abused and damaged for life. But I cringe every time I read or hear about the problem being ‘acknowledged’, ‘looked into’, and pledges for reparations and accountability; because what I don’t hear is ‘Why?’ Why is this happening. What is the root cause?
Let me not anoint myself as advisor to the church—I lack the credentials. But I do know that the process of root-cause analysis works. It works in the healthcare sector; it has worked in the airline industry. That process can be applied in any setting, including organized religion. Has the church asked the series of ‘why’ and ‘why’ questions and drilled down to the bottom of it? Maybe the exercise of digging down and deep may reveal that at the root of it all lays power, or perhaps economics, or even celibacy, or maybe a surprise. Who knows!
What we do know is that we want to see an end to sexual abuse in the church, and holding priests accountable after the fact isn’t the only answer. Prevention is. For that, we need to know the cause. The root cause.