Volume 37 Number 6 | December 2023

How Do We Make the Hard Thing Easier to Do?

K. Lindsey Davenport-Landry, DCLS, MLS(ASCP)CM, ASCLS Board of Directors

Lindsey Davenport-LandryIn the clinical laboratory we are required to utilize critical thinking and decision-making skills every day. Looking through the microscope, examining an organism growing on a plate, or reviewing a tricky antibody workup requires decision making and use of our learned skills. Many of the decisions we make are evidence based, and we use our education to guide our decisions. Education gives us reasoning on why things work and what are the expected outcomes.

Now, what do we do when there is a situation we have never encountered? Most of the medical laboratory professionals I know would refer to their resources and utilize established procedures and systems to help identify what steps should be taken next. We are problem solvers; we like to get to the root of a problem and give the evidence-based answer. But not every instance is cut and dry. Sometimes feelings get involved and decisions have to be based on the right or ethical thing to do. When it is easy to determine if something is right or ethical, that is great. Often situations are more complicated; that is when it is harder for me to ensure that the decision is impartial and not based on feelings.

“Creating an atmosphere where people feel comfortable speaking up and know that the first reaction will not be retaliatory will create a culture of safety and, in turn, allow people to make safe and ethical decisions.”

I am currently in a position where I oversee testing and laboratory personnel. In the supervisory realm of job duties, the training received is often through experience. The training has not been presented to me as evidence-based but more as, “This is the culture we would like to see.” The scientist part of my brain wants to do things in an analytical way, and often human interactions are not that easy. So, I challenge you to read the following scenario and think about how you would handle the situation if you were working side-by-side with this person. Then think about how you would handle the situation if you supervised this person.

Scenario: You are working on the bench next to a fellow laboratory scientist who has worked in the department for just over a year. You notice when they are pipetting to make a dilution that they push the plunger all the way down so all the liquid in their pipette goes into the tube. (They should push the plunger down until the first stop.) They do this for all of their dilutions.

Take into account that people do not normally do things to be malicious. Does the person have the tools and resources they need? Is the person trained; are they competent to perform the task they are performing? Why are they making this mistake; is there something going on at work, in their personal life, or are they just struggling with the procedure? These are all facts that must be reviewed before making a quick judgement about the situation and reprimanding a person for an error.

Many healthcare systems, including the U.S. Department of Veterans Affairs (VA), are working to be high reliability organizations (HROs), and part of that is ensuring there is a just culture. In my own words, for simplicity’s sake, just culture is when blame is not automatically placed on the person who made the error. Instead the organization first looks at the system to ensure there are no flaws in the system making the error likely to occur. The idea behind this thinking is to allow everyone, as part of the system, to continually identify and minimize gaps in processes so that errors are less common.

Back to the scenario, how do you, as a co-worker, handle a person making a procedural error? Think about it for a minute.

  1. Do you let it go and assume it was a one-time error? If you do not stop them in that moment, are you just as responsible for the error because you knew they were doing something incorrectly?
  2. Do you say something to them? See what they say and, if needed, explain the why behind what was done incorrectly. That pipetting mistake could lead to wrong results and incorrect diagnosis or treatment of a patient. Would you feel comfortable explaining to them in that moment that they are making an error and show them how to correctly pipette? Then, do you follow up by telling your supervisor? Who else is making this error, or is this person making the same mistake at other benches?
  3. Do you tell your supervisor, and let them handle it (that is why they make the big bucks anyway)? Allowing the supervisor to handle the situation may be easier, and if you do not feel comfortable having this conversation, it is a great option. Just let the supervisor know swiftly so nothing is reported out. If you wait too long, then erroneous results could be reported out and a provider could act upon the results.

Based on what you decided to do, if you chose to let this error go, think about why you allowed this error to occur. Does your workplace allow people to make errors and self-report? Or, if the error is reported, is there an investigation into why that error is occurring, or does the person who made an error automatically get in trouble?

To be an HRO, you should work to determine if the person making the error does not understand the process. If so, the organization—in this case, the laboratory department—should work to correct the error and not punish the person. The error should not have been allowed to be made. A system where opportunities to minimize errors is the ideal state, such as watching a person perform testing when they are learning and at intervals thereafter to ensure no bad habits have creeped into the process.

Choosing to intervene at that moment is ideal. You are “stopping the line.” This is a method in which you see an error and you stop it before anything bad can come of the situation. Being empowered to do this is an important part of a just culture. However, it can be very uncomfortable, especially if the person making the error has more experience, is not an easy person to talk to, or takes everything very personally. That is when doing the right thing is hard. Having an uncomplicated way to say, “Hey, can you stop for a moment? I think I just saw you pipette differently than what is in the procedure,” may be all that needs to be said to stop the line and get clarification. It also gives a moment to stop and assess the situation and get someone else involved if needed.

Handing the information off to the supervisor is completely okay. It would be appropriate that they handle a situation, but ensure that you do speak up. It is our duty in the laboratory to provide the most accurate and timely result; if we have the possibility that there is a result going to be reported that is wrong, ethically we need to speak up. We need to ensure that the error cannot occur in the future. There are many reasons a person may not pipette the way they are instructed to for a procedure, but correcting the behavior and ensuring they have the tools to do it correctly is the beginning to creating a just culture and an HRO.

I asked you to think through what you would do if you were the supervisor in this situation. Would you handle things differently? Do you feel comfortable speaking up? Maybe more importantly, do you think your employees feel comfortable speaking up when there is an error being made? Creating an atmosphere where people feel comfortable speaking up and know that the first reaction will not be retaliatory will create a culture of safety and, in turn, allow people to make safe and ethical decisions.

I just scratched the surface of high reliability organizations, just culture, culture of safety, and ethical decision making. These are not just buzz words, but guiding principles that can aid in the creation of a better healthcare system when staff feel safe in admitting errors and create a safer organization. Please continue reading about these topics and make it easier to do the right thing.

K. Lindsey Davenport-Landry is Chief Medical Technologist at Iowa City Veterans Affairs Health Care System in Iowa City, Iowa.