In the News
March 16, 2010 - the Wall Street Journal’s Laura Landro dedicated her health care column to hospital culture, medical error and balancing accountability. Landro looks at the case of Julie Thao, a nurse who was criminally prosecuted after giving a patient the wrong medication. The findings of the post-event investigation at St. Mary’s Hospital, led by the Institute of Safe Medication Practices, was published in this month’s Joint Commission Journal on Quality and Patient Safety. Landro cites David Marx in her piece, noting that “every hospital in America is wrestling with how to hold practitioners accountable for key safety behaviors.”
Marx addresses the Julie Thao case in Whack-a-Mole: The Price We Pay for Expecting Perfection. Read the chapter here.
About The Book
A financial meltdown. A rash of airliner crashes. Cities caught off guard by predictable natural disasters. An under-serving, error-prone healthcare system. What do they have in common?
Everything.
David Marx, author of Whack-a-Mole: The Price We Pay For Expecting Perfection, explores the role of human error in society, from aviation and healthcare, to driving and parenting—and where accountability rests for those errors, especially when they take the life of another.
After 20 years of observing and advising high consequence industries, Marx, CEO of Outcome Engineering, is convinced that society’s system of accountability has gone terribly awry.
“Our screwed-up notions of accountability have created an insurmountable barrier to better outcomes,” says Marx. “True accountability has simply devolved into a game of Whack-a-Mole.”
Marx uses insightful and often humorous stories to challenge our tendency to demonize people who make mistakes that cause harm, while also advocating that we abandon our “no harm, no foul” approach when reckless behaviors cause no undesirable outcome.
What People are Saying
“[Whack-a-Mole is] worth reading for its success at illustrating important features of duty and responsibility. The technique used throughout the book is the introduction of nuances of the idea of ‘no harm, no foul.’ Author David Marx makes his statement of an idea, then adds an understandable and approachable example to illuminate the ideas.”- Carl Metzgar
Professional Safety Magazine, Feb. 2010 (PDF Download)
“Punitive and blame-free discipline systems don't reduce healthcare errors. But an alternative system offers effectiveness...and justice.”
- Carol Latter
Prevention Strategist, Summer 2009 (PDF Download)
“No one wants to be punished. No one wants to contribute to an accident. So why do people keep violating rules they are aware of and committing errors that someone has already been penalized for?”
- Rick Darby
AeroSafety World, July 2009 (PDF Download)
“...the Whack-a-Mole game costs us dearly, in lives that will continue to be lost due to our failure to learn from mistakes, and in resources that could be put to better use.”
- Institute for Safe Medication Practices
Medication Safety Alert!, August 27, 2009 (PDF Download)
“While Whack-a-Mole is not, per se, a business book, the lessons contained in it could give you an entirely new take on the system of discipline within your organization. It is an easy and interesting read and it holds a lesson that every leader—from the floor supervisor to the CEO—should learn.”
- Charles M. Cooper
America's Best, Sept/Oct, 2009
Useful Links
Book David Marx for a speaking engagement
Media and Press information PDF
The Joint Commission: Sentinel Event Alert
TrainingMag.com: Maybe Managers Should "Whack-a-Mole"
More Than Grand Rounds: Patient Love Means Saying You're Sorry.
More Comments
"Marx gives us hope that regulators will be convinced to find a more appropriate balance between system and individual accountability than is evident today. We can tread a better path than Whack-a-Mole. In a word, brilliant!" - Max Stevens, Retired Deputy Director of the Civil Aviation Authority of New Zealand"Marx’s analytical tools provide an interesting framework for thinking about current events such as our banking and economic crisis or the contamination of food products with melamine in China." - Frank Byrne, President, St. Mary's Hospital, Madison, WI
