Health care practitioners expect punishment for errors

AORN Journal,  Sept, 2005  

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Despite widespread recognition that placing blame and doling out punishment for medical mistakes are counterproductive to patient safety, health care providers still fear punitive action from their licensing boards as a result of a medication error, according to a June 23, 2005, news release from the Institute for Safe Medication Practices (ISMP). More than 1,500 licensed health care providers, including physicians, pharmacists, RNs, and licensed practical nurses, responded to a recent survey by the ISMP regarding the anticipated response of licensing boards to medication errors.

The survey found that 93% of respondents believed that their licenses would be restricted in some way if they were involved in a fatal medication error. At least one in three respondents believed that their license would be placed on probation (ie, 41%) or suspended (ie, 33%), and nearly one in five thought their license would be revoked (ie, 19%). Respondents thought that errors involving policy violations would result in written reprimand (ie, 39%), mandatory remedial education (ie, 40%), or action taken against their license (ie, 47%). Even if the error never reached the patient, 30% believed they would receive a verbal or written reprimand or be required to obtain remedial education.

The survey results describe a disconnect between health care providers' anticipated response by their licensing boards and advice from national safety experts and the Institute of Medicine report To Err Is Human, which deafly refute the value of punishment for unintentional acts such as errors. Fear of punishment from licensing bodies may contribute to underreporting of medication errors and hinder efforts to understand their causes.

ISMP Survey Shows Healthcare Practitioners Expect Punitive Action from State Boards Following Errors (news release, Huntingdon Valley, Pa: Institute for Safe Medication Practices, June 23, 2005).

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