Despite a long-time understanding a problem exists and wide agreement that medical errors
represent a serious public health problem, challenges persist around collection of accurate data
on the occurrence of errors (Rodziewicz, Houseman, & Hipskind, 2022). The answer to the
question of what constitutes a medical error has not been clearly established making
measurement, analysis, synthesis, and evaluation of the true size and scope of the problem
difficult (Rodziewicz, Houseman, & Hipskind, 2022). About half of states require reporting of what
is termed “never” or “sentinel” events (serious incidents or errors that should not occur if safety
procedures are followed) like a surgery performed on a wrong limb which are non-reimbursable
under CMS guidelines. However, reporting requirements cover a small fraction of all harm events
and errors (Meyer, 2019).
Additionally, Rodziewicz, Houseman and Hipskind (2022) found that health care professionals
experience profound psychological effects such as anger, guilt, inadequacy, depression, and
suicide due to real or perceived errors. The psychological impact combined with fear of reprisal
can cause healthcare providers and clinical staff to hesitate to report an error, minimize the
problem, or even fail to document the issue (Rodziewicz, Houseman, & Hipskind, 2022).
Even though data suggests that a majority of errors are out of individual clinician’s control, it is
difficult to change a culture of non-reporting driven by fear of punishment. Rather than placing
blame, administrators and review boards need to move toward eliminating the blame-shame-
discipline structure and move toward a prevention and education structure that incorporates
learning and improvement efforts, targeting system redesign and a reporting culture in which
providers feel safe to report (Rodziewicz, Houseman, & Hipskind, 2022). Moore and Bates (2020)
concluded that creating such a culture entail fostering a safe and reliable environment of
transparency, safety, trust, and accountability. To achieve a culture change, organizational
leaders need to articulate the vision for the culture of safety, exemplify the behavior and
attitudes toward reporting that is expected of staff, conduct safety huddles with open discussion
so that the staff understands why changes are needed and in which employees are engaged as
trusted and capable partners in change efforts.
References:
Meyer, H. (2019, November 9). With no national reporting system, volume of medical
errors is still unknown. Retrieved January 13, 2022, from Modern Healthcare:
https://www.modernhealthcare.com/safety-quality/no-national-reporting-system-
volume-medical-errors-still-unknown#:~:text=Challenges%20include%20defining
%20errors%20and%20avoidable%20harm%2C%20determining,factors%2C%20and
%20the%20perceived%20burden%20of%20
Moore, M., & Bates, V. (2020). Going from a culture of blame and denial to a culture of
safety. HealthManagement.org The Journal, 20(2), 122-125. Retrieved January 13,
2022, from https://healthmanagement.org/uploads/article_attachment/hm2-v20-
journal-web-martiemoore-goingfromacultureofblame.pdf
Rodziewicz, T., Houseman, B., & Hipskind, J. (2022, January 4). Medical error reduction
and prevention. StatPearls [Internet], digital. Retrieved January 13, 2022, from
https://www.ncbi.nlm.nih.gov/books/NBK499956/#:~:text=Fear%20of
%20punishment%20makes%20healthcare%20professionals%20reluctant
%20to,contributes%20to%20the%20likelihood%20of%20serious%20patient
%20harm.
