View "near misses" as a gift. Ms. Pugliese says hospitals need to eliminate the "culture of blame" that pervades our society. When something goes wrong, she says the natural tendency is to look for a culprit: Whose fault was it? Who didn't do what they were supposed to do? She says while an individual may be responsible for a mistake, usually it can be tied to a "systems breakdown," where the lack of a checklist or a system of checks and balances allows tasks to fall through the cracks.
She says hospitals should instead step back and view "near misses" — situations where something almost went wrong, but didn't — as a gift. It gives the OR team a chance to assess what happened during the surgery and determine what went wrong to allow the near-miss to occur. She says it's important to include front-line workers in these discussions, because often they can identify systemic problems that frequently cause issues with patient safety. "Maybe the staff doesn't have enough IV pumps that have programmable ways to prevent medication errors, so they have to use the other ones," she says. "You want to know what keeps staff up at night, what bothers them."