Errors, or mistakes, are part of the human experience. Nearly every part of our daily lives carries a risk of error, with results that fall along a continuum of no harm to tragic outcomes. Yet, despite our best efforts in our daily lives, we make mistakes or we are the victims of mistakes made by others; thus, mistakes also are a part of our professional lives. Despite conscientious attention and care by skilled, well-educated, and careful nurses, along with thoughtful use of sophisticated technology, following specific safety protocols, and relying on and continually improving clinical safety programs aimed at preventing medication administration errors (MAEs), these errors and near-misses still happen to patients.1–3 How we choose to ethically respond, both individually and collectively (eg, as an individual unit or as the profession of nursing), when MAEs or near-miss medication errors occur represents an opportunity to consider “the true north of our moral compass.” The intention of this column is to provide an overview of the clinical safety issue of medication errors pertaining to critical care nursing, followed by a discussion of relevant ethical considerations.The words mistake and error are used interchangeably in this column. The New Shorter Oxford Dictionary of English4(p847) definition of error is “a mistaken … belief… Something done incorrectly because of ignorance or inadvertence; a mistake.” A proposed adaptation of this definition, used in other work5,6 and in this column, refers to errors or mistakes as those “unintentional acts that may or may not result in harm that can be judged to be erroneous by practical and reasonable standards.”6 This definition was chosen because it allows for discussion of ambiguous MAEs (eg, near-misses or missed doses that result in no obvious harm to the patient) and obvious MAEs (eg, wrong drug, wrong patient, or wrong dose that results in obvious harm to the patient) in the context of the culture of the intensive care unit (ICU).6 So, if a prescribed medication dose was missed, did an MAE occur if the patient experienced no harm? The answer depends, in part, on the culture and standards of the unit in which this error occurred.6 In this column, MAEs are taken to be honest ones. That is, this column is concerned with errors that were not made with reckless disregard for patient safety, by incompetent or impaired registered nurses (RNs), by uncaring or maliciously minded RNs, or by unattended or known-to-be-malfunctioning equipment.Although concern for safe medication delivery has evolved during the past several decades, the Institute of Medicine’s publication, To Err Is Human: Building a Safer Health System,7 initially uncovered the shocking extent to which medical errors, especially medication errors, were seriously harming and killing patients in the United States. In this landmark report, data extrapolated from multiple studies of fatal health care events (errors) that occurred during millions of hospital admissions in the United States conservatively estimated that up to 98 000 people died each year as a result of medical errors. Medication errors represented a significant percentage of medical errors. More recent research of medication errors8 indicates that at least 1 medication error per day happens to every hospitalized patient and that at least 25% of the errors are preventable.With the shock that errors were much more frequent than previously suspected came the realization that safety in the system of health care delivery needed to change through both an analysis of safety of medication management systems and a paradigmatic shift in how medication errors were reported and handled within health care institutions.7 Besides major policy initiatives to establish safety standards by various federal organizations, such as the Joint Commission on Accreditation of Healthcare Organizations, the Veterans Administration, and Institute of Medicine, clinical strategies emerged. These strategies included computerized order entry systems, medication bar-coding systems with corresponding patient wristbands, and “smart” intravenous pumps. A recent follow-up study on the safety outcomes of computerized medication order entry systems found a very significant reduction (almost 50%) in the likelihood of medication errors, indicating that approximately 17 million medication errors are prevented per year.9 However, this type of new technology is not a panacea for reducing medication errors, because, at least in part, it introduces another level of complexity into a system of care and creates another avenue for errors, such that MAEs actually do not occur less frequently, as has been suggested in other studies.10,11Medication administration is one of the highest-risk RN responsibilities and carries a significant risk of harmful errors.2,12 Medication errors most often are due to dosage calculation errors, actual administration errors including faulty technology, dose or drug omissions, transcription errors, and administration errors, almost all of which are preventable.13 Multiple layers of complexity within the milieu of the ICU could contribute synergistically to an ICU environment in which MAEs could occur.2,14,15 These include the physical attributes of the ICU environment, communication systems or leadership issues,1,7,16 the sociocultural milieu of the ICU that influences patterns and lines of communication and collaboration,2,17 patient-related factors such as sophisticated equipment that limits space around the patient, and the pathophysiology of critically ill patients that contributes to physiological instability (see Table 1).Although medication administration is carried out in the midst of many concomitant activities or interruptions7,18,19 (eg, ongoing conversations with other team members or family members, watching the patient, monitoring machines, and responding to alarms), one literature review suggests that inconsistent empirical evidence is available to support the notion that these interruptions have deleterious consequences on patient care.20 Evidence does exist, however, that although fewer medication errors occur in the ICU than in non-ICU settings, the ICU medication errors cause greater harm to patients.2,14,15 Note that estimates of medication error frequency in adult ICUs are variable, because standard definition terminologies are lacking, error-detection technologies differ among hospitals, and relevant patient acuity illness differences exist among ICUs.21 In addition, some MAEs are not realized until a nurse has time to reflect on the chaos of the day, when events are remembered.17Furthermore, clinicians should be cautious in accepting the prevailing perception that the process of medication administration, particularly in critical care nursing, is simply the isolated task of giving a patient a drug. Medication management research tends to present medication administration as simply the final step of the medication management system, and the step where errors are most likely to occur—the step for which nursing is primarily responsible.2,7,19Although the complexity of the ICU environment does not provide an excuse for medication errors, it offers a framework through which medication management processes, including thoughtful analysis of actual medication errors, can help reduce the likelihood of future errors. Similarly, although safety standards, policies, and continuing professional education synergistically aim to reduce medication errors to the lowest possible level, achieving completely error-free medication management and administration is not only difficult, but likely not possible.Conscientious nurses do not intend to make mistakes. Medication administration errors happen in the midst of daily work and are sometimes not recognized until a nurse has time to reflect on the shift.17 However, how nurses choose to respond to the occurrence of an MAE should reflect the ethical traditions of nursing.Disclosing MAEs, or any errors in the context of patient care, is not an easy action. Despite calls for a paradigmatic shift in reporting MAEs from the “name, blame, and shame” of individuals to analyses of systemwide problems that led to the error, MAE reporting remains a clinical problem.2,19,22,23 Not only does the “name, blame, and shame” response to errors cause the individual RN to experience shame, humiliation, self-incrimination, deep sadness, separation from coworkers, and guilt,24 it has been linked to job loss and, rarely, suicide.25 From an epidemiological perspective, blaming an individual contributes to the serious problem of underreporting medication errors.5,7,19 A positive work environment in which healthy relationships are expected and nurtured is required to culturally shift away from blaming and shaming an individual when an MAE occurs. The American Association of Critical-Care Nurses’ (AACN’s) Standards for a Healthy Work Environment26 emphasize the importance of healthy relationships among coworkers as an essential workplace resource. A safe work environment will help decrease errors.27When a nurse realizes that a medication error has been made, an opportunity to make an ethical decision is presented. The questions are, when, how, and to whom should an MAE be reported? In spite of the complexities of the market-driven, cost-containment business approach to health care delivery, RNs are still expected to provide responsible care and be fully accountable within their scope of practice. Provision 4 of the American Nurses Association (ANA) Code of Ethics states, in part, “The nurse is responsible and accountable for individual nursing practice.”27 In the first statement of that provision, “Acceptance of accountability and responsibility,” a legal contract is assumed with the public.28(p43) The contract is that RNs will “exercise judgment in accepting responsibilities.”28 Patients, coworkers, and other health care team members expect that nurses will be responsible and accountable for their practice. When MAEs are discovered, nurses have a moral obligation to account for the mistake and participate in an analysis of what led to the mistake.In the context of the ethical domain of nursing practice, accountability implies using judgment to do the right actions, whereas responsibility includes liabilities associated with a specific role.28 Medication administration, as a nursing responsibility, falls within the nursing scope of practice and is performed according to professionally established standards. Registered nurses are responsible for safely administering medications to patients. When an MAE occurs, the moral decision to expose professional fallibility, even in the context of the system approach to medication management, necessitates an admission of personal vulnerability and potential legal risk,29,30 and also may expose vulnerabilities in the medication management system. Professional responsibility that is consistent with the ANA Code of Ethics includes providing competent care, exercising professional judgment, and practicing within the scope of critical care nursing. These attributes of nursing are also essential corequisites for professional moral agency. However, the realities of working in today’s health care environment, with evolving business models of health care delivery and increasingly stringent cost-containment structures, present unquestionable challenges to the moral agency of many RNs. Being trustworthy and honest requires a significant commitment to safe patient care, not only by the individual RN but also by the team caring for each patient.Being accountable for one’s actions includes disclosure of the error and taking steps to address the root causes that contributed to the error. Disclosure, in a morally safe environment (ie, an environment that supports ethically sound professional practice), also offers an opportunity for nurses to provide “good” nursing care in the context of professional moral obligations of responsibility and accountability. Disclosure is also an opportunity to practice virtuous characteristics, especially honesty and trustworthiness.Patients in the ICU and their families are vulnerable because of their limited ability to control many aspects of their personhood, including their ability to speak directly for themselves, a sense of intimidation by the critical illness experience that stems from having little control over their environment, and invasive technology and painful procedures that can undermine their autonomy. For patients to overcome this vulnerability, or powerlessness, a climate of trust is essential, and being worthy of that trust placed on a nurse is described as one of the most important virtues in medicine and health care.31Among all of the health care team members, nurses are in closest contact with patients and their families.32 The public has repeatedly con sidered nursing as the most trusted profession in national polls.33 Patients and their families place their trust in nurses to keep them safe from harm and provide good and safe care. This trust placed in nurses by patients and families implies that nurses must inherently possess the character traits worthy of that trust—being trustworthy and honest—to provide safe care throughout their time in the ICU.31,34,35 Accepting the responsibility of medication administration and disclosing when an error has occurred represent a nurse’s way to express the virtue of trustworthiness to the patient.A patient’s expectations of a nurse are linked not only to his or her role within the ICU but also to the ethical standards of professional practice. Nurses are socialized in professional roles, like critical care nursing, through education, the culture of the ICU, and the expected standards and policies that govern safe practice. Meeting these standards of responsibility and accountability, as stated in Provision 4 of the ANA Code of Ethics,27 requires cultivating moral virtues such as trustworthiness and honesty. Practicing these virtues helps link professional ethical standards with the technical skills, expertise, and professional knowledge needed to meet the aims of nursing, thereby establishing a trusting nurse-patient relationship through which nursing care is provided.36(p34) Asking for and accepting someone’s trust imply honesty—that is, the nurse will use wisdom and judgment to do the right thing.Challenges to honestly disclosing an MAE often are rooted in the ICU and hospital culture. Barriers to being honest might be beliefs that disclosing an MAE will result in blame and punishment, distancing, gossip, and distrust from other nurses and physicians; that events will be misconstrued or that others involved will not speak up; or that a reputation will be irreparably marred.30 Provision 6 of the ANA Code of Ethics states, “The nurse participates in establishing, maintaining, and improving health care environments and conditions of employment conducive to the provision of quality health care and consistent with the values of the profession through individual and collective action,”27 which means that all RNs, in their units of practice, have a professional moral obligation to create and sustain a workplace culture that reflects the central values of nursing.37 The importance of a healthy work environment—one that fosters collaborative practice and supports the work of nurses in providing care that is as safe as possible—has been recognized by nursing and medical professional organizations. Policy statements, such as ANA’s Bill of Rights for Registered Nurses27 and AACN’s Standards for a Healthy Work Environment,26 discuss components of a healthy workplace environment that should be present to promote and facilitate ethical work environments. Cocreating a healthy environment within the ICU depends on the synergistic moral character of the unit RNs and leadership.37Trustworthiness and honesty, particularly in situations of recognizing and choosing to report and disclose MAEs to patients and/or their families, require that nurses have the requisite knowledge and skills to take proper actions. Research has shown that 4 factors affect nurses’ willingness to act on an ethical dilemma or question, such as whether to report an MAE: ethics knowledge, clinical expertise, concern for ethical issues, and nurses’ perceived level of influence in their unit.38 The following text includes strategies to consider in situations of MAEs and provides a framework through which to take ethical action when MAEs occur and mechanisms to prevent MAEs in the ICU.A healthy work environment that relies on respectful communication and collaboration between team members to ensure patient safety is one that is respectful and depends on trustworthiness between team members.39 Nurses have a professional moral obligation to speak up when their scope of practice, skills, knowledge, or abilities are challenged in a way that compromises patient safety. When you become overwhelmed or see coworkers who are struggling with a critically ill and unstable patient, speak up, offer help, and accept help. These are not signs of weakness but rather signals of professional accountability and putting the needs of the patient ahead of everything else.Do the right thing, and admit that a mistake was made. Discuss the error with the nurse manager. The discussion should include how to disclose the error to the patient and/or the family, who should be present, and who should make the actual disclosure. Be mindful that an MAE admission may help maintain and protect a relationship, based on trustworthiness and honesty, with your patient and other team members. Not disclosing errors has negative consequences for the involved RN5,24 and does not help improve the system of medication administration or the medication management process.7,19 Not disclosing errors deprives patients and their families of important clinical information that facilitates their personal autonomy about postmistake treatments and care, and it erodes trust in nursing and personal trustworthiness. Consider discussing MAEs and near-misses during change-of-shift reports or handoffs, and during in-house educational sessions.Lead or join efforts in your ICU to change negative responses to MAEs. Research demonstrates that most MAEs are the result of a system problem and not the person at the bedside.40 Therefore, supporting coworkers who have made an error provides an opportunity to practice the moral virtue of kindness and the professional moral obligation to support other nurses.Use a standardized, evidence-based approach to medication management processes, including medication administration, to reduce the potential for MAEs. Ensure that orders are entered in the patient’s chart and that the RN looks at the original order before giving the medication. During ICU rounds, many licensed providers suggest treatment plans and medication options. Missed or misunderstood verbal communications easily can result in an MAE. Verbally clarify all ambiguous medication orders or medication orders that appear inconsistent for your patient with the provider who wrote the order. Carefully monitor medication administration technology.Is the wording of disclosure policies subtle, so that not reporting an MAE is justifiable? Work with your governance committees to ensure that policies are transparent and provide a framework and guidelines for disclosing MAEs. Policies that endorse the autonomy, accountability, and responsibilities of nurses enable nurses to take a leading role in planning for the disclosure and leading the disclosure conversation. Policies that clearly articulate the role of ICU nurses enable nurses to have conversations with patients, rather than avoiding patients or families and thus putting their trustworthiness at risk.41AACN’s Healthy Work Environment Standards include the concepts of developing proficient communication skills, fostering collaboration, participating in decision making throughout the ICU, ensuring that the competencies of each RN match the needs of the patient, striving to value the work of RNs, and cocreating a positive environment with nursing leadership. A healthy work environment is built on the collective moral character of the RNs along with leadership and reflects the values of nursing.27,37Nurses are “at the sharp end” of medication administration and are professionally morally obligated to safeguard their patients. Participation in research and policy development gives voice to professional practice safety issues about the entire process of medication management, including medication administration.A morally safe work environment means that nurses’ work environment is one in which professional moral values, including both spoken words and nonverbal cues, encourage and support safe nursing practices. Creating and sustaining a workplace in which moral values can flourish also means that nurses can feel safe in enacting moral accountability in all facets of their practice. So, when an MAE occurs, nurses know that acknowledging that an error has occurred will be met with support, kindness, and encouragement to fully participate in the analysis of the error without fear of punishment or social isolation from others.Acknowledging that an MAE has occurred can elicit uncomfortable feelings of personal vulnerability and professional fallibility, with feelings of guilt, panic, remorse, self-doubt, and self-blame.5 However, the act of acknowledging an MAE within a morally safe environment, along with medication error policies that include root cause analysis of errors, recognizes the vulnerability not only of patients who might have been harmed but also of nurses who are indirectly harmed by the error and become a second victim of an MAE.42 Acknowledging an MAE and accepting responsibility, as part of the system in which the error occurred, may not decrease the distress experienced but instead can lead to positive practice changes.5 Caring for oneself with compassion and kindness during the distress that follows an MAE is reflected in Provision 5 of the ANA Code of Ethics,27 in which nurses have a moral obligation to care for themselves as they do for others. Furthermore, this self-care fosters a similar attitude among others.43Medication errors remain a serious clinical practice issue in critical care, despite systematic analyses and actions, including sophisticated technology, to prevent them. Because of their clinical presence at the bedside of critically ill patients and by accepting the responsibilities within their scope of practice, RNs are the last line of defense in safeguarding patients from MAEs. These errors can have serious, life-threatening consequences for patients and are devastating, career-marking experiences for RNs. Nursing has a responsibility to participate in the development and assessment of safe medication management processes. However, when those systemwide safeguards fail, nurses have a moral obligation to accept responsibility and account for failures. Enacting these obligations facilitates the cultivation of honesty and trustworthiness. Supporting colleagues during an MAE is an opportunity to grow in kindness and to practice good nursing care—care that aims to help our patients regain their health or move toward their death in ways that are consistent with their life values and goals.35We thank M. Kathleen Clark, RN, PhD, Professor of Nursing, and Tess Judge-Ellis, DNP, ARNP, Associate Professor (Clinical), University of Iowa, College of Nursing, for helpful comments during the development of the manuscript. The views expressed herein are those of the author and do not necessarily reflect the views of the University of Iowa Hospitals and Clinics.