Errors show system faults, not individual problems
Medical errors, which kill as many as 98,000 hospitalized Americans annually, do not deserve individual blame but are an indictment of faulty health care systems, according to health experts participating in an interactive Web cast, "Practice Issues: Creating a Culture of Safety," hosted by NursingCenter.com.
According to Lucian Leape, MD, PhD, of the Harvard School of Public Health’s department of health policy and management, nurses can take the lead in moving health care from individual blame and punishment to systematic safety management. He specified health care systems that encourage teamwork, automation, and the reporting of errors, which should increase accountability and the overall quality of patient care.
Leape, along with David Keepnews, JD, MPH, RN FAAN, assistant professor in the department of health and clinical sciences at the University of Massachusetts in Lowell, led the Web cast discussion about medical system failures and the changes necessary to create a culture of patient safety.
The Web cast, which was moderated by Diana Mason, PhD, RN, FAAN, editor-in-chief of the American Journal of Nursing, followed Leape’s presentation at the plenary session of the American Nurses Association 2000 convention, held this summer in Indianapolis. The session was sponsored by the American Journal of Nursing.
Nurses vital for patient safety
Emphasizing the important role nurses play in health care, Keepnews underscored that "nurses are vital to changing the culture of institutions and successfully creating a safer patient care system."
Leape added that "It is the front-end health care professional who comprises the largest component of the health care work force and is involved in the daily, hands-on provision and management of patient safety who must be the primary contributor to this health care ideal."
Leape, who published the groundbreaking "Harvard Medical Practice Study" on medical error in the Journal of the American Medical Association in 1991, said current practice has been to focus on the individual rather than the system when medical errors occur. Calling it the "blame and train" approach, he said it results in a health system where the incidence of errors is getting worse, rather than improving. He noted that about 10% of people suffer adverse events upon hospital admission.
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