Tips from BESD: It’s time to stop punishing people for making medical errors

Staff Development Weekly: Insight on Evidence-Based Practice in Education, June 18, 2010

Dr. Lucian Leape, a member of the Quality of Health Care in America Committee at the Institute of Medicine and adjunct professor of the Harvard School of Public Health, stated that the single greatest impediment to error prevention in the medical industry is "that we punish people for making mistakes." Leape (2009) indicated that in the healthcare organizational environment in most hospitals, at least six major changes are required to begin the journey to a culture of safety:

  1. We need to move from looking at errors as individual failures to realizing they are caused by system failures
  2. We must move from a punitive environment to a just culture
  3. We must move from secrecy to transparency
  4. Care must change from being provider-centered (doctor-centered) to being patient-centered
  5. We must move our models of care from reliance on independent, individual performance excellence to interdependent, collaborative, interprofessional teamwork
  6. Accountability must be universal and reciprocal, not top-down

Editor's note: This excerpt was adapted from the June 2010 issue of Briefings on Evidence-Based Staff Development. Discover all the benefits of subscribing to Briefings on Evidence-Based Staff Development.

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