The statistics related to medical errors are staggering:

• On average, Americans are treated correctly only 54 percent of the time. (New England Journal of Medicine study, 2003)
• Approximately 1.16 million patient safety incidents occurred in over 40 million hospitalizations in the Medicare population alone. (HealthGrades Patient Safety in American Hospitals Study, 2007)
• 1 of every 10 patients who died within 90 days of surgery did so because of a preventable error. (Department of Health & Human Services' Agency for Healthcare Research and Quality study, 2008)

The vast majority of medical errors that are uncovered are preventable. As a result, medical centers around the country are trying to understand what causes errors and how they can prevent them. One way to reduce the negative impact of errors is to make sure that help and expertise is available to frontline employees when they encounter complex patient reactions that are not fully understood. In addition to being available, however, frontline employees must also perceive that asking for help is valued and encouraged.

Seeking The Advice Of Others

When individuals are confronted with complex situations, they often prefer to turn to other people for information and input. Why? It’s only through this interpersonal give-and-take that a more complete understanding of the situation can emerge. Given this, the question in complex and dynamic situations is not so much whether individuals will seek others out, but instead, who individuals will seek out.

Obviously, the organization would want individuals to seek out the person with the greatest amount of expertise relevant to the situation at hand. But, unfortunately, the reality is that this often isn’t how it works. Sometimes resident experts are unavailable. Sometimes they don’t possess adequate interpersonal skills. And sometimes they make individuals asking for their input feel incompetent. For these and many other reasons, individuals may be reluctant to seek advice and input from the most knowledgeable source.

Our research focused on these interpersonal relationships and how they contribute to nurses’ decisions regarding whom to seek out for advice and input. We found that two different types of situations emerged:

1. Strong Relationships Create Easy Access. If individuals have strong interpersonal relationships with experts on the unit, then these relationships enable them to confidently approach these individuals for input and advice – even if they perceived the experts to be very busy and somewhat inaccessible. In other words, the interpersonal relationship provides the nurse entrée into the experts’ inner circle.
2. Availability and Willingness Encourage Interaction. If individuals do not have strong interpersonal relationships with experts on the unit, then they needed a strong signal regarding the experts’ availability. In other words, if nurses do not know the expert well, then they need a strong message communicating to them that the expert is both available and willing to help.

Understanding the Impact On Strategic Staffing

This second situation has significant implications for staffing decisions currently being made within numerous hospitals. Many hospitals have moved to strategic staffing models that increase the number of contract and float nurses. Because these contract and float nurses are frequently moving across units (and hospitals), it is difficult for them to develop strong interpersonal relationships within any given unit. Said differently, they are almost always likely to feel as if they are outsiders.

To help contract and float nurses effectively deal with complex situations and reduce the negative impact of errors, our research suggests that the organization must send a strong signal that help is available and that seeking out this help is encouraged. One way that some hospitals have chosen to do this is by designating a formal consulting role within the unit. Individuals are chosen for this role based on their experience and expertise. Essentially, these professionals spend part of each shift as on-unit consultants and answer questions.

By defining helping and mentoring as part of an individual’s role, the organization signals to others that this person has relevant knowledge and expertise, and that they are available to provide advice and input. It becomes their job to help others and this is communicated clearly on the unit – particularly to the contract and float nurses. This signal, in turn, opens up the communication and increases the likelihood that nurses will seek out the advice and input they need to help diagnose and understand complex situations.

A Climate of Help Seeking

In addition to signaling that help is available, organizations must also ensure that the broader cultural norms communicate that seeking this help is valued and that individuals can seek out this help without fear of retribution, getting in trouble, or being made to feel as though they lack competence.

Creating a culture that enables people to feel free to admit, “I just did something and I’m not sure what to do now” without fear of retribution is key. From a managerial standpoint, organizational leaders need to ask, “Do people in this organization feel safe bringing negative situations or problems up the chain of command?”

Action steps

Our research suggests that organizations can undertake several specific and concrete actions to better manage complex situations and reduce the negative impact of errors.

1. Signal that help is available. Organizations must first send strong signals that help is available, accessible and that it is safe to seek out this help. One way to do this is to formally designate several individuals on the unit as consultants. These individuals should be selected based on both their interpersonal skills and their expertise. Several of their other job demands would need to be reduced in order to provide them the time to help others.
2. Perform a cultural audit. Organizations need to evaluate the culture of the organization periodically. Can people raise questions and concerns to managers and supervisors and get the help they need? What is happening that signals it’s not acceptable or allowed to ask for help? If managers find themselves often asking their subordinates, “Why didn’t I know about this sooner”, then the first place they need to look for an answer is in the mirror. Because for some reason, the managers have created a culture that discourages the upward communication of negative information.
3. Ensure fairness of decision making. Transparent decisions that are based on good data, provide opportunities for input, and that are consistently applied across individuals are likely to be perceived as more fair. Similarly, organizations must investigate errors in a fair and just way. If it’s an honest mistake, then it’s honest mistake, but intentionally violating a policy is a different matter altogether and is a punishable offense.
4. Showcase successes. When a nurse is confronted with a complex situation, seeks out help, and successfully resolves the issue; make an example of this successful behavior. Post write-ups of successful responses, those who sought out help and made the situation correct. This is a way to implicitly communicate the behaviors that are expected, valued, rewarded and supported.

Beyond the Bedside

Healthcare isn’t the only industry in which errors can garner catastrophic results. Error management is critical to any organization that’s dealing with complex technologies coupled with negative outcomes and not a lot of time to recover. Healthcare is also not the only industry to utilize an increasing number of contract workers to manage fluctuations in demand.

We need look no further than NASA, which experienced significant errors on the Challenger, Hubble and Columbia missions. There were engineers on the front line who knew things weren’t right, but their concerns fell on deaf ears. After Columbia, the agency performed a cultural audit and found that lower-level employees believed that upper management didn’t care about them raising safety issues.

Trying to manage in the small space between a complex event and negative consequence requires that people find help to resolve problems. By creating a culture of help-seeking, managers can save a lot of operational time and money, and avoid damage to individual and organizational reputations.

David A. Hofmann is associate dean for the MBA Program, academic director of the Leadership Initiative, and professor of organizational behavior/strategy at UNC’s Kenan-Flagler Business School, dhofmann@unc.edu or 919-962-7731.