Case Management

Sneak peek: Appropriate response when staff acknowledge mistakes helps ensure patient safety

Case Management Weekly, December 5, 2012

You're reviewing a case file and discover that a ­patient's recent readmission is due to a medication ­prescribing error made by a physician. Do you report it?

The answer to this question probably depends on the culture at your organization, says Vivian Miller, BA, CPHQ, LHRM, CPHRM, DFASHRM, author of How to Create a Just Culture: A Nurse Leader's Guide, published by HCPro, Inc.
A facility's culture comprises the characteristics of the group as a whole, which can determine how individuals behave with each other and how they react to different situations, Miller says.
Individuals who work in a just culture, which views errors as opportunities for education, can report mistakes without being subject to immediate discipline or penalties. As a result they are likely to speak up if they see that something is wrong. However, individuals who work in an organization whose culture is punitive might fear a reprimand or possible termination for reporting ­errors. Chances are they won't take any action, which can potentially put patients at risk, says Miller.
Protecting patient safety requires more than ­making the right medical choices for them. Patient safety also requires that healthcare providers be able to report ­incidents freely without fearing negative consequences, says Miller.
Creating a safer culture requires that hospital ­leaders embrace the idea and promote it from the top down, says Miller. Leadership must set the tone for an organization, ensuring that simple mistakes are viewed as learning opportunities, not the basis for punishment, says Miller. "We are imperfect, human beings and, therefore, we will make mistakes," she says.
Ultimately, the goal is to create an environment where staff members feel comfortable discussing problems and are willing to acknowledge their own mistakes. Organizations also should be willing to take steps to respond to errors in a more positive manner, she says.

Editor's note: This article is adapted from an article in the December Case Management Monthly More information about Miller's book is available at

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