The Culture Of Blame In The Healthcare System

It is the goal of all healthcare providers and organizations to provide quality care to all patients without error. The truth is, even healthcare providers make some mistakes. The question is, when an error occurs who is to be held responsible? Is it, the nurse who administered the wrong medication, due to being overworked and lack of staff to help? Or is it the Healthcare Organization (HCO), because they should have fixed the staffing issues. There are so many factors that contribute to an error. I believe each situation should be properly investigated, before placing blame where it should or should not be placed.

"Johns Hopkins patient safety experts have calculated that more than 250,000 deaths per year are due to medical error…" (John Hopkins Medicine). This soaring number has caused medical errors to become the third leading cause of death in the United States. For many people, medicine seems foreign and unknown. People who have lost loved ones due to medical error desperately look for a reason, and many times that blame falls upon doctors. Media has put a negative connotation on doctors as well, causing their reputation to plummet whenever a hospital procedure turns badly. A renown surgeon and author, Atul Gawande, uses his knowledge and experience to give people a new perspective on medicine. In the article "When Doctors Make Mistakes," Gawande uses rhetorical appeals: ethos, pathos, and logos to prove the need for a change in the medical systems and procedures. He analyzes how the public looks at doctors, giving a new perspective to enlighten the reader that even the best doctors can make mistakes.

One of the most critical factors which contribute to the number of preventable cases of healthcare harm is the culture of silence surrounding these cases. The fear of medical providers to report incidences is related to the possibility of punishment and liability due to a medical error (Discovery, 2010). The criminalization of some acts of medical error has resulted in job dismissal, criminal charges and jail time for some healthcare workers. This is despite the fact that the system they are working in helped to create the situation which led to the error in the first place. Human error, due to fatigue and system errors can result in deadly consequences, but by criminalizing the error it effectively shuts down the ability to correct the root problem. Healthcare workers, working at all levels within the medical system, can provide valuable input on how to improve the processes and prevent harm from occurring (Discovery, 2010).

A medical error can be defined as a preventable and adverse effect of care and one that changes the lives of all those involved-whether it be the patient, the nurse, or the physician (Grober & Bohnen, 2015). Prior to reading The Wall of Silence by Gibson and Singh (2003), I was unaware of not only how common medical errors in healthcare are, but also how they affect people from all walks of life. Medical errors do not only occur in underserved regions with understaffed medical facilities, but they can also occur in what many consider the “best” areas with fully staffed and fully equipped hospitals and medical centers. Before reading this text, it was my belief that errors in healthcare occurred rarely and at best, effected one patient per every

In healthcare systems, there is a concept of fair and just culture. That concept is important to manage the risk. In any organization, errors can happen. But, the best first tool to understand the error is to report it when it happens. Reporting error in healthcare contributes to minimize the risk of recurring.

I agree with you that under reporting medical errors compromise patient safety.  It is important to report mistakes not only to appropriately follow up with the affected patient but also the improve  the protocol if its needed.  I also think that fear plays a huge part on nurses not reporting errors. I think that they are afraid of the consequences or penalties for the errors. I enjoy reading your post.

Preventing such hospital acquired conditions can save millions of dollars for the hospitals by sidelining unnecessary expenses for the acquired conditions. Frontline nurses can handle and prevent the occurrence of never events by incorporating a culture of safety through best nursing practices. The safety culture includes the ways in which the organization handles and reacts to issues or mistakes concerned with the safety in the organization, and also the notion the members of the organization have towards the safety. A high safety culture is crucial for preventing those errors from happening. Their occurrence can be prevented by expecting the risk in advance and embracing the evidence based practice. To minimize these errors Institute of Medicine (IOM) ordered the healthcare insurers including medicare and even the private insurance companies to provide higher incentives for the hospital acquired condition irrespective of the financial barriers and considerations. In order to motivate towards better care, IOM exhorted the insurers to encourage the hospitals following evidence based prevention strategies through rewards and provide advantageous rate adjustments for hospitals which provide quality care, and also allowing the admission of high risk patients with

By keeping the lines of communication open between leaders and staff, healthcare organizations can encourage and empower nurses to solve blame game issues without fear of punishment by management. Leaders and nurses must work as a team and are capable of providing safe and quality environment. When an error or incident happens, many leaders investigate everything and everyone except themselves. In the process of patient care, harm might occur; the culture often prefers to blow the blame game whistle instead of learning from the mistake. Nursing in fear, often refrain to openly admit mistakes and errors, which hinder the objective to ensure everyone is cared with compassion and dignity.

A “just” culture is necessary in healthcare to promote an environment where mistakes are brought out in the open and analyzed for ways to prevent errors from repeating. Therefore, there is a need for a consensus across the healthcare industry. To transform healthcare from the blame culture to a “just” culture will require change that extends beyond hospitals to the industry (Ross, 2015). The change has to be unified across all aspects of healthcare.

In the course of operations, all healthcare organizations experience errors occurring. Policies and procedures must be in place in order to minimize the severity of errors and the impact on patient safety. When an error occurs, there are two types of causes of the failure”

A critical lack of availability is negatively impacting healthcare, because Information Technology (IT) lack of control over cloud computing, leading to more issues involving availability, reliability, integrity and confidentiality (Kuo, 2011). Availability is a rising risk in the healthcare fields for Information Technology (IT) management using cloud computing (Kuo, 2011). Despite the hype of cloud computing advantages, research confirmed 58% of firms using the cloud have no idea if the cloud is within the U.S. and forty-two% do not know where the cloud servers are placed (Turner, 2013).

Disclosing medical errors is considered necessary by patients and practitioners. They are advised to disclose in the form of an apology when necessary and appropriate. When a medical error causes damage to the patient, it seen as not acceptable because a patient goes for treatment in order to get better not to get worse therefore it calls for the situation to be addressed. When a medical error is not disclosed, the fellow peers who have witnessed the error must decide whether they should remain silent and keep the error to themselves or reveal the error to the higher up, although it would be in good faith to report the medical error to a higher up, unless it has caused harm or long-term damage to the patient. (Youngson. p. 69) There are many hospitals that the practitioners keep the errors made to themselves and do not disclose the medical errors to the families of patients or the patients themselves. Medical errors become a topic of conversation if the family of a patient or the patient themselves become aware about the error. Medical errors are something that should be disclosed in a good faith manner

In today's modern world with plenty of technology, it is hard to believe that we cannot figure out how to reduce Medical errors. The issue of medical error is not new in health care organizations. It has been in spot light since 1990's, when government did research on sudden increase in number of death in the hospitals. According to Lester, H., & Tritter, J. (2001), "Medical error is an actual or potential serious lapse in the standard of care provided to a patient, or harm caused to a patient through the performance of a health service or health care professional." Medical errors

Keeping patients safe is essential in today’s health care system, but patient safety events that violate that safety are increasing each year. It was only recently, that the focus on patient safety was reinforced by a report prepared by Institute of medicine (IOM) entitled ” To err is human, building a safer health system”(Wakefield & Iliffe,2002).This report found that approx-imately 44,000 to 98,000 deaths occur each year due to medical errors and that the majority was preventable. Deaths due to medical errors exceed deaths due to many other causes such as like HIV infections, breast cancer and even traffic accidents (Wakefield & Iliffe, 2002). After this IOM reports, President Clinton established quality interagency

Nurses are given much responsibility during patient care. They are the ones that closely work with the patient and administer the patient’s medication. When a medication error occurs, nurses are the ones that are blamed for the error. This can result of them losing their job or their license to practice. Therefore, nurses are scared to report any incidents that may occur during a medication pass. Considering this, nurses must establish a culture of safety, where they can openly report medication errors, and have the opportunity to learn from their mistakes rather than being punished right away for their errors. The purpose of this paper is to examine the attitudes, beliefs, and values that affect nurses when reporting a medication error,