Medical errors go unreported with the main reason being fear of
repercussions (Wolf & Hughes 2008). Healthcare professionals who
make mistakes are generally so devastated and embarrassed that they
conceal their mistakes or attempt to defend themselves. Usually,
mistakes are attributed to failure and it is difficult to admit they failed
their patients, themselves, and their organization. Following serious
medical errors healthcare professionals may feel shame and guilt and
blame themselves causing them to feel self-doubt. They also fear
career-threatening disciplinary actions and malpractice litigation and
liability. Leader’s lack of support and protection only reinforces these
fears and these negative consequences can lead to only reporting when
errors can't be covered up or when serious harm occurs. There is also
the idea that errors that caused no harm need not be reported as these
near misses are seen as unimportant. Error reporting can also be
incomplete or full data may not be provided with the difficulty of filing
errors reports. A standardization in the information needed to be
reported and collected would make the data more accurate and allow
for better comparisons as well as prevent future errors.
There is an outdated mantra in healthcare "name you, blame you,
shame you" (Wolf & Hughes 2008). Many healthcare organizations are
trying to shift to a more open and safer environment where
professionals can feel comfortable reporting errors to help understand
why the errors occurred and how to prevent further errors. It also
opens communication to have professionals feel open about talking
about co-workers possibly unsafe behaviours. The cultural norm of
placing individual blame needs to shift toward a culture of safety and
reward reporting to increase reports of all kinds of errors. For this to
happen healthcare professionals need to feel they can safely report
without fear of punishment. With the current culture of anxiety and
shame regarding errors and subsequent reporting it will take time to
transition to a culture of safety where reporting is normal with a focus
on education and safety rather than punishment for errors.
Reference
Wolf, Z. R. & Hughes, R. G. (2008).ErrorReportingandDisclosure.
Agency for Healthcare Research and Quality. Retrieved
from: https://www.ncbi.nlm.nih.gov/books/NBK2652/
