Some experts hold that the term “error” is excessively negative, antagonistic and perpetuates a culture of blame. When these errors come to light, they can tarnish the reputation of the healthcare institution and the workers. These actions or lack thereof can contribute to an evolving cycle of medical errors. This can cause staff to hesitate to report an error, minimize the problem, or even fail to document the issue. Many healthcare institutions have rigid policies in place that also create an adversarial environment. Unfortunately, failing to report contributes to the likelihood of serious patient harm. While they fear for patients’ safety, they also dread disciplinary action, including the fear of losing their jobs if they report an incident. Clinicians equate errors with failure, with a breach of public trust, and with harming patients despite their mandate to “first do no harm.”įear of punishment makes healthcare professionals reluctant to report errors.
This can also lead to a loss of clinical confidence. The threat of impending legal action may compound these feelings. Health care professionals experience profound psychological effects such as anger, guilt, inadequacy, depression, and suicide due to real or perceived errors. Examples include administering a medication to which a patient has a known allergy or not labeling a laboratory specimen that is subsequently ascribed to the wrong patient. Examples are not strapping a patient into a wheelchair or not stabilizing a gurney prior to patient transfer.Įrrors of the commission occur as a result of the wrong action taken. A lack of standardized nomenclature and overlapping definitions of medical errors has hindered data analysis, synthesis, and evaluation.Įrrors of omission occur as a result of actions not taken. Due to unclear definitions, “medical errors” are difficult to scientifically measure. Yet, one of the most challenging unanswered questions is "What constitutes a medical error?" The answer to this basic question has not been clearly established. All individuals on the healthcare team must play a role in making the provision of healthcare safer for patients and healthcare workers.Īll providers know medical errors create a serious public health problem that poses a substantial threat to patient safety. Healthcare organizations need to establish a culture of safety that focuses on system improvement by viewing medical errors as challenges that must be overcome. Part of the solution is to maintain a culture that works toward recognizing safety challenges and implementing viable solutions rather than harboring a culture of blame, shame, and punishment. By recognizing untoward events occur, learning from them, and working toward preventing them, patient safety can be improved.
It is challenging to uncover a consistent cause of errors and, even if found, to provide a consistent viable solution that minimizes the chances of a recurrent event. Medical errors are a serious public health problem and a leading cause of death in the United States.
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