Julian Perez, J.D., Chief Legal Officer, dentalcorp
Dental offices are fast-paced, complex enterprises that adhere to rigorous infection prevention and control (IPAC) standards and other procedures designed to promote safety and prevent incidents. Despite the myriad regulations and controls in place, accidents inevitably happen. The question, then, is why?
To understand why you must put yourself in another’s shoes. Imagine that you are the Regional Manager or Principal Dentist at ABC Dental as you read the following scenario and think about how you would react.
It’s a busy Thursday evening at ABC Dental. Patients come and go, the phones ring, team members flow in and out of clinical areas, deliveries arrive, instruments are reprocessed, operatories are occupied, disinfected, and turned over. Amid the buzz, Mina, a rock star dental hygienist overseeing the steri-centre, begins to daydream about the upcoming long weekend. She wants to get everything done and officially start her minivacation. At the end of the day, Mina loads one final sterilizer with expertly prepared pouches and cassettes. She’s kept up with the ebb and flow of the day, and she’s proud of herself. She’s about to start the cycle when someone calls for assistance. Mina pops over to Operatory 6 to find her friend Trish finishing the setup for tomorrow’s first patient. Mina lends a hand, says her goodbyes, and signs out. On the car ride home, Mina has a feeling like she left the stove on; she cannot remember starting the autoclave. She tells herself she must have and forgets about it.
On Friday, the day-sheet columns are stacked. Serena, a temp dental admin, is filling in at the front desk for Marni, who called in sick. Marni usually backs up the steri-tech when required. At around 9:30 am, the Practice Manager notices the steri-centre is a bit disorganized. Realizing both Mina and Marni are absent, he considers asking one of the other dental hygienists or dental assistants to help. That would put the office further behind schedule, and there are already patients growing anxious in the waiting room. Decided, he swings by the front desk and asks Serena if she knows how to run a steri-centre. Eager to impress, she replies, “yes.” Serena proceeds to the sterilization bay and unloads the autoclave Mina had left the night before. Serena cleans the instruments that have piled up, packages some cassettes for sterilization, and restores order.
Later that day, pouches from the sterilizer Serena unloaded are distributed throughout the operatories and used on both hygiene and dental patients.
Tuesday after the long weekend, Mina is back in the office. She’s arrived early and has started reorganizing the steri-centre. Doing that, she notices some unsterilized pouches in the storage area – all from load D-152. Mina attempts to find the other pouches from that load, but most seem to be missing. After some investigating, Mina discovers they were used by two dentists and a dental hygienist Friday before the long weekend. The entire office is stunned and doesn’t understand how this could have happened. What to do?
After incidents like these occur, team members are often reluctant to admit what they did (or didn’t do) to contribute to an error. In workplaces where such isolated incidents lead to discipline, that fear is strengthened. Unfortunately, this kind of reaction results in mistakes being buried rather than brought to the forefront. In learning organizations with just workplace cultures, leaders often decide that an incident investigation should be performed. A step in the right direction, such investigations too frequently end with the conclusion that the source of the incident was human error or a failure to comply with process. Mina got distracted. Serena made a mistake when unloading the sterilizer. The clinicians were too hurried to confirm the chemical indicators were activated. This view treats systems as fundamentally safe and non-compliant humans as threats to those systems.
Traditionally, you might have told Mina and Serena to “try harder” and “pay more attention.” But pause to consider what you would have said to them when their decisions to depart from process resulted in positive outcomes. Perhaps you would have hailed their creativity or felt reassured about the resilience of your team.
To truly learn from (and prevent) incidents, we need to adopt a new thinking around incident causation. We need to learn—and be brave enough—to see human errors for what they usually are: symptoms of issues that lie deeper within an organization¹. If we can accept that this is the case—and a wealth of research from a broad range of safety critical industries has shown it to be so—it becomes apparent that determining an accident was caused by human error is not the conclusion but the beginning of an investigation.
To adopt the new way of thinking about human error, you must appreciate that we only label things as human error in hindsight. If we put ourselves in the shoes of the operator, we would see that the erroneous actions they took made sense to them in the moment. For this reason, one who wishes to understand and learn from accidents must practice empathy: they need to understand how and why that action seemed appropriate at the time. They must gain a clear and precise understanding of the situation as it happened. For example, when Serena indicated that she knew how to run the steri-centre, was she rewarded for her can-do attitude?
The revised approach to understanding incidents recognizes that people often operate under time pressures, with limited resources and must reconcile competing goals, such as clinical efficiency, productivity, and safety. The new way of thinking acknowledges that systems are not inherently safe; rather, the people within a system work together every day to make that system safe. When we embrace a culture of safety, we view people as assets instead of liabilities.
Although one may understand the benefits and truth of this new way of thinking about error; accepting it can be uncomfortable. Saying an employee made a mistake is easy. Digging deeper and reflecting on how workplace norms and cultures may have contributed is harder. Adjusting our approach to error takes time and team commitment. But there is one thing we can start doing immediately: practicing empathy. Next time there’s a SNAFU, put yourself in the position of the person who committed the error. Seek to understand how their decision could have seemed right when they made it. If you have the courage to undergo that exercise, you’ll learn more (and be able to identify effective solutions to complex problems) than if you simply chalk another mishap up to human error.
[1] Dekker, S. (2002). The Field Guide to Human Error Investigations (1st ed.). Routledge. https://doi.org/10.4324/9781315202778