“Publicity is justly commended as a remedy for social and industrial diseases. Sunlight is said to be the best disinfectant,” wrote future Supreme Court Justice Louis Brandeis in 1915, advocating for the concept of transparency as a cure for corruption. Hidden problems can’t be fixed. Whether due to malfeasance or ignorance, problems are not always surfaced. Sometimes, someone needs to pull back the curtains to let the light shine on it. Or to use a different analogy, someone needs to blow a whistle.
The idea of ferreting out problems and bringing them to light has a long tradition in America, with its legacy of free speech and free press. The first legislation to protect federal whistleblowers, the False Claims Act, was passed in 1863. And investigative writers such as Ida Tarbell and Upton Sinclair reveled in their reputation as “muckrakers,” digging up problems ranging from dangerous working conditions to tainted meat to market manipulation by trusts.
As I said, problems are not always due to ill intent – the vast majority are not. In healthcare, we have moved away from considering errors as a sign of individual incompetence, and seeing them instead as a symptom of a system that is not optimally designed to promote the desired outcomes and prevent the wrong ones. But in a system as large and complex as a hospital, many problems would go unrecognized by those who can help optimize that system. Hence the need for “sunlight,” in the form of what we now call Safety Learning Reports (formerly known as incident reports).
We encourage clinicians and all staff to report issues, especially when it’s just a potential issue that never actually causes a problem for a patient – a near miss – that might otherwise be brushed off as “no harm, no foul.” That allows us to analyze the issues, find the root causes, and make the necessary changes to prevent future problems. We learn from them. The issues that are reported in SLRs can take many forms: incorrect medications, equipment malfunction, communication failures, etc. In order to address issues of equity, we have recently pioneered a new type of SLR, one around issues of dignity and respect. We always have more to learn.
Knowing about problems is the first step toward improvement. Yet admitting problems is hard. Which is why I am so proud of the fact that Children’s Minnesota has over 5000 safety learning reports in 2019, an all-time high. It’s not that I’m glad we have problems. I am thrilled that our people are becoming more and more willing to bring them forward.
By one measure, it’s a hard time for whistleblowing. In New Orleans, a construction worker who raised safety concerns before the fatal collapse in October of the Hard Rock Hotel being built there appears to have been reported to immigration officials in retaliation for his speaking up. And the response to the whistleblower in the impeachment case shows the courage needed even to reveal problems anonymously. While healthcare has made great strides in moving from a culture of blame to a culture of safety, I understand the emotions that make speaking up about problems difficult. This is why while we do not encourage anonymity, we do allow SLRs to be submitted anonymously, something not all health systems embrace. I am encouraged that only about 10% of all SLR’s are anonymous at Children’s, and that number is decreasing.
So keep those lights shining, keep those whistles blowing. And kudos to every one of our 5000 whistleblowers – three cheers!