Protecting Nurses from Unnecessary Blame Should be the Role of Engaged Hospitals by Dev Raheja, Author-Safer Hospital Care

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What is an Engaged Hospital?

The Gallup organization defines a staff/manager without passion for doing right things as a disengaged and not engaged employee. According to their poll nationally, engaged employees made up only 29% of the work force [1].  The remaining employees were either not-engaged (56%) or actively disengaged (15%). I have witnessed one of the best hospitals with similar numbers from a Gallup poll. Not-engaged and actively disengaged employees tend to work in a substandard manner.  Most important, disengaged managers are often responsible for disengaged and un-passionate safety culture. The numbers are likely to be higher for hospitals because of complex handoffs and complex communications through software. If 71% staff/managers are disengaged or unengaged, I have to conclude that hospitals are more disengaged than engaged. Looking deeper, you will find that they are disengaged not only from patients (over two million infections per year and over 100,000 deaths) but also from nurses in their own organizations. Instead of blaming the system, they often blame nurses for medication errors. According to Beth Boynton’s book Confident Voices, 80-97 percent nurses experience verbal abuse! Any hospital that allows this undignified treatment of employees is obviously a disengaged hospital.

Hospitals need to be engaged. An engaged hospital is the one that is passionate about “First, prevent harm to patients proactively”, and “Treat caregivers with dignity they deserve.”


Why Hospitals are Disengaged from Nurses?

The lack of understanding of the science of safety seems to be the biggest reason for their wrong actions. Patient safety is science, not art. It is based on rigorous identification of all possible hazards in the treatment procedures and protocols, with disciplined rules and procedures to prevent human error from triggering any given hazard. A hazard is any source of harm including the inadequate management. According to the science of safety, at least two things have to go wrong to trigger a fatal error like the one at Alta Bates Summit Medical Center, where the death of a cancer patient was initially ascribed to an inappropriate dosage of a nutrient administered intravenously instead of through a feeding tube by a 23 year replacement nurse during an employees strike on September 25, 2011. Is it her fault that she did not have enough experience? Or, is it the system at fault for hiring the inexperienced nurse to fill in for the experienced nurses on strike?  Even young doctors make mistakes. Many patients refuse to go for surgery during July-August months because fresh medical graduates cannot be trusted. Some hospitals give orientation to temporary nurses as a safeguard before they allowed to be with patients.  I think inadequate procedure and inadequate safeguards are to be blamed more than the nurse. Most systems are set up to fail and the nurse happens to at the end of the chain of hazards. If one still has doubts, see my video “The Science of   Patient Safety” at


What can Hospitals Do to Avoid Blaming Nurses?

One answer is “work smart, not hard” by using one of the principles of risk management, which states that about 20 percent inadequacies in the system are responsible for 80 percent high risks. Therefore, identify those inadequacies that result patient harm and proactively develop teams of doctors and nurses to improve the procedures, protocols, and safeguards.

The second suggestion is to understand and explore concrete applications of the theory of profound knowledge set forth by the world-quality guru Dr. W. Edwards Deming who taught Japan how to be the best in the world in quality. He defined quality as fitness for use from the point of view of the user (patient). To a patient, fitness for use means error-free medical care (quality and safety), treatment with dignity, and timely recovery (no hospital acquired infections, no wrong surgery, no wrong medication, etc.). How can we achieve this level of integration? Deming used to say “working hard won’t help if you are working on the wrong things.”  Blaming nurses instead of blaming systems is obviously a wrong thing to do. He describes his recipe as a “system of profound knowledge” consisting of four parts:

(a) appreciation of the system, (b) knowledge of variation: the range and causes of variation in quality, (c) theory of knowledge: the concepts explaining knowledge and the limits of what can be known, and (d) knowledge of human nature and its limitations.

Of these, the appreciation of the system is the key to becoming an engaged hospital. The hospitals must understand that all caregivers including labs, pharmacy, and radiology department must work together as a system. They should not be working in silos where everyone is doing best from their own point of view and no one is doing what is best for the system. A treatment system is a composite of people (nurses, physicians, patients, support staff), procedures (surgery procedures, medication procedures, discharge procedures), environments (infections, air quality), equipment (defibrillators, ventilators, pacemakers, MRIs), software (EHRs, patient monitoring, software in medical devices), interactions between systems and between people (handoffs), and facilities (accessibility to OR, location of test labs) with a common system goal of patient safety. Ideally, representatives from all these areas must work together as a clinical micro-system. Otherwise, the system will become dysfunctional. If logistics do not permit everyone to work together, then there must be someone accountable for integrating the work. The integrator’s job should be similar to a maestro in a music orchestra where every musician plays the right tune at right time.

Deming stressed the role of top management in making sure that a process is in place for integration while constantly re-evaluating how well the teams are working together. Management must make sure that everyone understands that most adverse events originate from hazards latent in the system. It is the system that needs to be fixed first, then the people.

Deming was very clear on the role of psychology and its influence on management style. “The worker is not the problem. The problem is at the top management” [Ref. 2]. It is the management’s job to direct the efforts of all components toward the aim of the system. The first step is clarification: Everyone in the organization must work towards the aim of the system. Management must assure good processes are in place; procedures for making sound decisions are in place and must not only stay informed on the resources needed, but provide them. Deming further said” There is no substitute for knowledge. Wisdom is knowing what you don’t know.” He was the master on how to become engaged.


[1] Raheja, D., Safer Hospital Care, Taylor & Francis, 2011

[2] Deming, Edwards, W., Out of Crisis, MIT Press, Massachusetts, 2000.

About Dev Raheja

A respected and sought out expert on hospital and medical device safety, author Dev Raheja draws on his 25 years of experience as a risk management and quality assurance consultant to provide hospital stakeholders with a systematic way to learn the science of safe care. He uses evidence-based safety theories and tools taken from the aerospace, nuclear, medical, and chemical industries to identify the combination of root causes that result in an adverse event.  He applies analytical tools that can effectively measure hospital efficacy; establish evidence between Lean strategies and patient satisfaction. His focus is on using various types of innovation including accidental, incremental, strategic, and radical, and establish a culture conducive to high return on investment.

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