Article that proposes a method of reducing medical errors by focusing more on the “what”
and “why” of the error rather than "who" committed the error. Discussing errors and near
misses can be valuable learning experiences, not only for the individuals/departments
involved but the organization/healthcare system as a whole (Medical Errors: Focusing
More on What and Why, Less on Who, 2007). When the article was written, the Institute
of Medicine estimated that over 1 million preventable errors/mistakes occurred in the
United States with approximately 98,000 of those being fatal (Medical Errors: Focusing
More on What and Why, Less on Who, 2007).
The article discusses various reasons that can impact error reporting. No one likes to make
mistakes or admit when they make mistakes, however, no matter how difficult it is to
admit, honesty is always the best policy. After numerous years of specialized medical
training, health care providers can experience shame, guilt, or a sense of failure if they
misdiagnose a patient or make a medical error which can lead to a decreased willingness
to admit their mistake (Medical Errors: Focusing More on What and Why, Less on Who,
2007). Teaching institutes often instruct students how to manage conditions if errors occur
rather than teaching the importance of disclosing errors in and of themselves (Medical
Errors: Focusing More on What and Why, Less on Who, 2007). The complexity of the
reporting process can be a huge deterrent to error reporting. Additionally, the treat and risk
of malpractice litigation can decrease the likelihood that individuals will self-report or
disclose when an error occurs (Medical Errors: Focusing More on What and Why, Less on
Who, 2007).
When errors/mistakes are appropriately addressed and discussed, this increases the
likelihood of quality improvements to patient safety being implemented and sustained
long term (Medical Errors: Focusing More on What and Why, Less on Who, 2007). To
help eradicate the negative associations and establish a non shameful culture surrounding
the disclosure of medical errors, it will be important that leaders emphasize and utilize
these experiences as learning opportunities. Additionally, it will be vital that leaders and
organizations provide health care providers with routine continuing education discussing
common errors, new processes, or procedures that are being implemented throughout the
department/organization as preventative measures. It will also be important that
organizations create an error reporting system that is nonpunitive and confidential that
provides solutions, and new processes/procedure recommendations to avoid similar
situations in the future (Medical Errors: Focusing More on What and Why, Less on Who,
2007). Ultimately, it is vital that leaders create an environment where health care
providers feel comfortable working collaboratively and do not feel embarrassed or fearful
if a mistake is made.
Reference:
Medical Errors: Focusing More on What and Why, Less on Who. (2007). Journal of
Oncology Practice, 3(2), 66–70. https://doi.org/10.1200/jop.0723501
