Historically, organizations have followed the "name, blame, and train" model of quality improvement, and yet, we continue to be plagued by substandard patient outcomes. Our investigations have focused on our people rather than the systems in which they operate, and our people became the broken part that needed to be fixed. Resilient systems are built to withstand inevitable human error, not to prevent it or punish for it. In this discussion, we will use real case examples to understand why a systems-based approach is better for the people we lead and the patients that we care for.
Learning Objectives:

Upon completion, the participants will be able to describe why punishment for simple human error is counterproductive to quality improvement.
Upon completion, the participants will understand several ways in which system factors contribute to human errors.
Upon completion, the participants will be able to describe how system resilience in patient safety relies on expecting rather than preventing human error.