Jorge and Mindy are both seasoned phlebotomists who work in the same city at different hospitals. Both drew blood from the wrong patient last week. Fortunately, in both cases the errors were caught before medical mistakes could have occurred. Jorge was summoned into his supervisor's office. The conversation went something like this:
Supervisor: You know the policy, why didn't you check the ID band?
Jorge: I did check it, but the bar code scanner wasn't working for some reason. The ID band was creased or stained or something. But I remembered him from the day before and felt confident I had the right patient. I must have put the wrong labels on the blood tubes.
Supervisor: No, you drew the wrong patient. It could have been disastrous. You made a conscious decision to go against protocol, you exercised poor judgment. Your decision-making process broke down. This is healthcare, Jorge. You can't be careless and make assumptions like that, ever.
Jorge: Yes, I know. I made a mistake.
Supervisor: We can't have flawed thinking here. You need to change the way you handle this kind of situation. One more incident like this and we'll have to let you go.
Across town, Mindy was also called into her supervisor's office. The conversation went like this:
Supervisor: Mindy, you're one of our best phlebotomists. What happened?
Mindy: The scanner wouldn't scan his bracelet. I don't know why. I tried to locate another scanner, but couldn't. I drew him every day last week, so I felt sure I had the right patient. So I used the manual backup process.
Supervisor: The process you used was not the process we have in place when a scanner fails. You should have found another scanner or had arranged for his ID band to be replaced so your scanner would function properly. Besides, our manual method requires you to visually compare the labeled tubes to the ID band. If you had done that, you would have discovered your error.
Mindy: I know, I forgot about that step.
Supervisor: Our processes are all in place for instrument malfunctions, and our backup procedure is well established. How can we prevent this from happening again?
Mindy: I don't know the backup protocol that well. I've never had an ID band not scan. I think we all need more regular reviews of the backup processes. I don't think any of the phlebotomists know what the downtime plan is. I think we should bring it up at tomorrow's huddle on every shift. It should be part of everyone's annual competency assessment, too.
Supervisor: Thankfully, this didn't result in a serious incident. I'll check to make sure the downtime protocol is still in our SOPs, and remind the staff to review it. The next time something like that happens and you don't know what to do, ask someone. There's a process for every contingency here, so you should never have to guess.
Did you notice the different approaches to discipline? Jorge's supervisor reacted as if the employee was flawed and gave him an ultimatum. Mindy's supervisor recognized the process was flawed, and solicited her suggestion on how to fix it. Managers who focus on fixing broken people instead of a broken process rarely solve the problem. Instead, they leave the employee demoralized and deflated. Nobody wants to work for someone who thinks they're broken.
Empowered managers who focus on fixing the process---even if what's flawed is the thought process---will find that employees who are worth keeping are likely to fix themselves.