My Employee Made an Error - I'm Going to Discipline Them...Or Should I?
Marc Stern, MD, MPH
Two buddies, Frank and Harry, go out drinking for the evening. They match each other, drink for drink. By the time they leave, both their blood alcohol levels are well above the legal limit. They bid each other farewell, get in their cars, and head home. They both have about a mile to travel. A sheriff’s deputy on patrol observes Frank weaving and rolling through a STOP sign. She stops Frank as he pulls into his driveway. Unfortunately, Harry’s neighborhood has a little more pedestrian activity tonight. Harry also goes through a stop sign, but not seeing the person in the crosswalk, runs them over, killing them.
Should Frank and Harry receive the same punishment? Most readers will likely answer “No. Harry’s punishment should be harsher than Frank’s.”
Now imagine, instead, that Frank and Harry took ride-shares home. Still very hung-over, they both report to the county jail at 6 a.m. the next morning where they are both medication nurses. Frank completes morning pill pass without incident. Harry has a patient who’s supposed to get a large morning dose of insulin. Harry draws up the wrong type of insulin causing the patient to experience a massive insulin overdose. The patient is found dead in his cell during the next count. Based on reports from other staff who smell alcohol on their breaths, the nursing supervisor discovers that both Frank and Harry have reported to work under the influence of alcohol.
Should Frank and Harry be managed the same way by their supervisor? Most readers will likely also answer “No” for this scenario. If this is your answer, you probably applied the same thinking you applied in the first scenario.
In this article, I will ask you to arrive at a different conclusion: that from a personnel management standpoint, Frank and Harry should be managed the same. Your reasoning in the first scenario was based on the principles of our criminal justice system which bases punishment, in large part, on the outcome of the crime. Instead, I will argue that when managing employees we have to “switch off” our criminal justice reasoning. Managing staff and managing criminals is different and requires different reasoning and different approaches.
In brief, managing personnel differs in three major ways. First, we need to understand the reason for the inappropriate behavior. (For simplicity for the rest of this article, I will refer to the inappropriate employee behavior—whether the employee failed to do something they were supposed to do or did something they weren’t supposed to do—as the employee’s error.) Second, the supervisory action we take should be based on the behavior, not on the outcome of the behavior, because the outcome is often determined by luck. In the first scenario, for example, the difference between Frank’s and Harry’s outcomes (Frank got home safely; Harry killed a pedestrian) was purely a matter of chance: Frank was lucky, Harry was not. But their underlying behaviors were identical. Third, while we should not ignore accountability when dealing with employee errors, accountability is not our primary goal, as it is in the criminal justice system. Instead, the goal of addressing employee errors is to ensure that the system we’re operating does so safely and efficiently. In other words, the main focus of personnel action is the system, not the individual. Let’s look at these three elements in more detail.
Understand the Reason for the Behavior
For reasons that will become clear in a moment, before you can know how to deal with an employee error you must understand the reason for it. You won’t necessarily be able to figure out the root cause of the error, but you at least need to understand the circumstances. For example, an officer fell asleep at his post. Why? Knowing that he had been ordered to do two 12-hour shifts back-to-back, had 12 hours off (which, factoring in change of shift and travel to and from work, was not nearly 12 actual hours off), and is now on his second of two more mandatory 12-hour shifts, is critically important information. It sets a very different stage than the employee who falls asleep at his post during his first shift after two days off.
Base the Supervisory Action on the Behavior, not the Outcome: “Just Culture”
Now that we know the reason for the behavior, we are in a position to take supervisory action. To guide us in this, we will rely on the brilliant work of a human capital engineer, David Marx. In 2001, Marx published a landmark report entitled “Patient Safety and the ‘Just Culture’: A Primer for Health Care Executives.” The report was produced to address errors that were occurring with blood transfusions, but the principles that Marx lays out are applicable well beyond transfusions and even health care. They are fundamentally sound in any industry or profession, including corrections.
Though I have simplified it a little, Marx divides employee errors into three buckets.
Bucket 1: The Inadvertent Error
These are the errors we make because we are humans, not machines. They are errors that, given the circumstances, were predictable and unavoidable. The best way to figure out if you’re faced with an Inadvertent Error is to ask yourself: “Would anyone else (would I) have made the same mistake in his/her shoes?” Take the example above of the deputy who fell asleep at his post after a grueling number of hours awake (at his supervisor’s insistence). Who among us would not have fallen asleep in the same circumstance? On the medical side of the jail, imagine the nurse who makes a serious—perhaps fatal—medication error. When the supervisor looks into the reason for the behavior, it becomes clear that: the medical unit is understaffed; another nurse had called in sick that day and no other nurses were brought in to back-fill so the medication nurse was doing three jobs at once; there was a new physician at the facility who was prescribing an unusually large number of prescriptions, so medication pass was long, and, at the time of the error, was running very late, so the nurse was rushing to make sure no one got their medications too late. Not only did the nurse make a human error that any of us would have made, one could easily argue that the error was predictable.
What action should a supervisor take when an employee makes an Inadvertent Error? SUPPORT THE EMPLOYEE! Discipline of any kind is not appropriate. A good employee—which we assume we have—is already acutely aware that he or she made a mistake and likely is not only remorseful, but feels guilty and embarrassed about their error. They are already chastising themselves (internal punishment); they will not benefit from any further discipline (external punishment). In fact, external punishment at this point may very well be harmful to the employee, and therefore to the agency, if the employee takes unscheduled time off, or worse, resigns. Instead, the supervisory action for an Inadvertent Error comprises two parts, one directed at the operation (which I’ll discuss later), and one directed at the employee, which is to be supportive. Help the employee understand that what they did was not their fault. If the outcome was very serious, e.g., fatal, the employee may even need a higher level of professional support.
Bucket 2: The Careless Error
These are errors we make because, though we’re trying to do a good job, we don’t always make the wisest choices. The best way to figure out if you’re faced with a Careless Error is to ask yourself: “Was this employee using ill-advised means, but in their heart was hoping to get to the right end?” Imagine the deputy assigned (by himself) to the mental health unit where there are several individuals on 15-minute checks for risk of self-harm.
The deputy knows he’s supposed to be checking on cells 1 and 2, but the individual in cell 3 is making a lot of noise and may be starting to flood his cell again. Thinking that the disruptive individual may trigger reactions from the rest of the unit and may cause property damage, the deputy concentrates his efforts for several minutes on cell 3, knowingly skipping his checks on cells 1 and 2. During that gap, the individual in cell 2 commits suicide.
What action should a supervisor take when an employee makes a Careless Error? COACHING. In this example, the deputy was trying to do the right thing. But he chose the wrong path. He failed to consider alternative actions that would have been safer, wiser, and more in line with policy. For example, he could have called for back-up. The nature of the coaching will depend, in large part, on what you discovered when you were trying to understand the reason for the behavior. Was the deputy not familiar with the policy that instructs staff to call for back-up? Did he think that asking for help was a sign of weakness (or would result in discipline)? Did he assume that everyone else was busy so no one would be available? Each of these possible reasons would lead to different coaching.
There is one caveat to add: the supervisor’s action I discussed above assumes that this is the first or a rare occurrence for this employee. For employees who make the same Careless Error—or even different Careless Errors—repeatedly, a different approach may be needed. That discussion is beyond the scope of this article, but depending on the circumstances may include actions such as job reassignment and/or discipline.
As with Inadvertent Errors, in addition to the supervisory action directed at the employee (coaching), there will also be an action we need to take directed at the operation; I’ll discuss that later.
Bucket 3: The Reckless Error
As the name implies, these are errors that reflect a lack of caring on the part of the employee. There was an expected behavior, policy, or rule, and the employee violated it for no good reason. The best way to figure out if you’re faced with a Reckless Error is to ask yourself: “Did the employee not really give a hoot?” Frank and Harry knowingly showing up at work hung over from a night out drinking barely a few hours earlier, is a good example of a Reckless Error.
What action should a supervisor take when an employee makes a Reckless Error? DISCIPLINE. The employee made a conscious decision to break the rules; this was not an understandable human mistake nor were they trying to do the right thing, just going it about it the wrong way. Discipline is appropriate and necessary. The nature of the discipline should be based on the nature of the error and is beyond the scope of this article. For the employee who is disciplined but not terminated, supervisory action sometimes also includes a small component of education or counseling. However, keep in mind that the key element of the Reckless Error is that the employee knew better and recklessly chose the wrong path; the employee truly did know the correct path. If you find that your supervisor plan includes education or counseling, that means you think that there is something the employee did not know. And if that’s the case, stop to ask yourself if this was really a Reckless Error or in fact is a Careless Error. Finally, as with the other two kinds of errors, here too, in addition to taking a supervisory action directed at the employee (discipline), we need to take action directed at the operation.
To be complete, I will mention another error that is beyond the Reckless Error: the Intentional Error. Such errors take us out of the personnel management realm and call for remedies in the criminal justice realm and are therefore outside the scope of this article.
Taking Action to Fix our Agency’s Operation
Earlier in this article, I said that responding to staff errors differs from managing criminal offenses in three ways. I will now address the third difference: while we should not ignore employee accountability, the goal of addressing staff errors is to ensure that the system we’re operating does so safely and efficiently, i.e., system improvement. Thus, whatever supervisory action we’ve taken with the individual employee resulting from an Inadvertent, Careless, or Reckless Error, we should always step back and explore what underlying system error led to, or allowed, this error to occur.
All the examples of employee errors I’ve used in this article should trigger a search for the system error or errors that led to—or could have prevented—the employee error.
The deputy who fell asleep at his post after being mandated to work too many overtime hours, or the nurse who made a medication error when trying to do three jobs at once, obviously erred because of understaffing. Until staffing levels are normalized, such errors will continue. For the deputy who didn’t check on other at-risk individuals in the mental health watch unit because he was focused on the disruptive individual, is there anything that can be improved during initial training or periodic training to help deputies make better decisions when faced with complex and stressful situations like this one? Would videos, table-top exercises, or mock scenarios be useful? And for employees like Frank and Harry who showed up at work under the influence of alcohol: Is our background checking process as robust as it should be? If Frank or Harry has come to work inebriated at other times, isn’t likely that other staff noticed, and if so, why didn’t they report him to his supervisor? Do we have a training or cultural deficit that needs to be addressed?
The search for the underlying system problem is sometimes easy, with an obvious underlying cause. More often, it takes more work to find the true underlying (i.e., root) cause of the error, a process known as Root Cause Analysis (RCA). RCA is beyond the scope of this article, but in short, during an RCA, we keep “peeling back the layers of the onion” by continuing to ask, “Why did this happen?” until we arrive at the deep-rooted error or problem from which the chain of errors flowed. It is only when finding and fixing this root cause that we are assured of preventing the next error.
Summary
In this article, I’ve described a framework for dealing with employee errors. The framework is more rational than the approach many of us currently use that is based on the outcome of the employee’s actions and only focuses on holding employees accountable. Instead, the framework I describe is based on the employee’s behavior itself, regardless of the outcome (which, based on
luck, might be better or worse), and includes supervisory actions that focus on what’s best for the agency to prevent such an error from recurring. Employees are still held accountable (via discipline) when appropriate (typically for a Reckless Error), but otherwise are provided support through their stress when the error was a human mistake that any of us could have made (an Inadvertent Error) or coaching when they were trying to do the right thing but went about it the wrong way (Careless Error). And, in all cases, we endeavor to find and repair the underlying system problem which caused or allowed the error in the first place.
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Marc Stern, MD, MPA is a general internist and former Medical Director at the Albany County Correctional Facility, NY, and Assistant Secretary for Health Care at the Washington Department of Corrections. He is currently Affiliate Assistant Professor at the University of Washington School of Public Health in Seattle, Washington. Dr. Stern also serves as Medical Advisor on the AJA Board of Directors. For more information, he can be contacted at marcstern@live.com
Reference
Patient Safety and the “Just Culture”: A Primer for Health Care Executives. David Marx, JD. https://nursing2015.wordpress.com/wp-content/uploads/2010/02/mers.pdf Accessed May 27, 2024