Nurses, Medical Errors, and the Culture of Blame

Abstract

In June 2004, an article in American Journal of Nursing reported findings of a three-year study of organizational culture, attitudes, and assignment of responsibility for patient safety in small, rural hospitals in nine Western states. The study found that most errors fall within realm of nursing practice and that physicians, administrators, and nurses themselves tend to see patient safety as largely a nursing responsibility. Asked to identify which profession has primary responsibility for ensuring patient safety, 96 percent of nurses and more than 90 percent of physicians, administrators, and pharmacists assigned primary responsibility to nurses. Only 22 percent of respondents believed that physicians, nurses, pharmacists, and administrators share responsibility for patient safety equally. Unfortunately, however, nurses and physicians differed on role of nurses in effecting change. Most of nurses indicated that they had several responsibilities in reducing medical errors, including reporting them, educating themselves and colleagues, serving as role models, making recommendations for changes in procedure and policy, reviewing reported adverse patient-safety events, and participating in investigations. Only 8 percent of physicians who responded to survey identified nurses as members of decisionmaking team. Nurses have a genuine impact on patient safety. Studies have found a link between patient safety and RN staffing and an increased rate of error when hospital nursing staff has a smaller proportion of RNs. These are worrisome findings in light of severe national shortage of nurses. Part of medical malpractice crisis, then, is confusion in health care system and how it affects role of nurse. There is no confusion in American Nurses Association's code of ethics. This document, first adopted in 1950 and revised in 2001 to reflect and embrace role of today's nurse, consists of a set of planks that set out nurses' fundamental values and commitments. They also offer a starting point for understanding how nurses should be involved in thinking about medical error, and why nurses blame themselves for medical errors. The first few planks are most important. These planks state that nurse's primary commitment is to patient (plank 2), and that nurse promotes, advocates for, and strives to protect health, safety, and rights of patient (plank 3). Interpretive Statements that accompany code add that nurses are committed to patient's health, well-being, and safety throughout patient's life span, and in all settings in which health care needs are addressed. Further, code directs that, as an advocate for patient, the nurse must take appropriate actions regarding any instances of incompetent, unethical, and illegal practice by any member of health care team or health care system or any action on part of others that places rights or best interest of patient in jeopardy. For nurses to function effectively in this role, they must be knowledgeable about code of ethics, standards of practice, relevant laws, and their own organization's policies and procedures. Moreover, when nurse is aware of inappropriate or questionable practice in provision or denial of health care, concerns should be expressed to person engaging in questionable practice. Attention should be called to possible detrimental effect upon patient's well-being or best interests, as well as to integrity of nursing practice. When factors in health care delivery system or health care organization threaten welfare of patient, concerns should be directed to responsible administrator. If indicated, problem should be reported to an appropriate higher authority within institution or agency, or to an appropriate external authority. The interpretive statements for third plank also remind nurses that they have a responsibility to implement and maintain standards of professional nursing practice. …