It’s Unfair and Unjust to Blame and Punish Nurses for Systemic Mistakes

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One sign that medical mistakes are a systemic problem is when you see headlines like this around the world, this time in New Zealand:

Elderly patient overdosed by hospital nurses on incorrect medication, died days later

As I wrote on LinkedIn

When nurses have more “accountability” thrown at them than autonomy… stuff like this happens. The mistake and the aftermath.

Nurses don't get to design the system. They don't get to set staffing levels.

“Following Mr A's death, Nurse C stopped working as a nurse and told the HDC she regrets the “pain and sorrow” caused to Mr A's family.

She also said nursing had “become a lot more time constrained and stressful over recent years”.”

But they get blamed when “they” make a mistake under time pressure and chaotic conditions. It's more accurately a systemic mistake that they were a part of.

It's unjust to blame individuals. It's counterproductive.

No wonder so many nurses are looking to leave their profession.

“But they should have noticed it was the wrong medication,” some will scream.

“I accept there were circumstances which contributed to this error. I also consider it possible that confirmation bias played a role in successive opportunities to be alert to the error being missed.

“It's human error… what can we do about it?” some will ask. Instead of throwing up our hands, what we can do is work to improve systems so that nurses aren't overly stressed. We can mistake-proof processes and systems. Leaders must work to help prevent human error. No amount of “training” alone fixes any of this.

Nurse B provided an apology letter to Mr A's family, outlining her “sincerest and heartfelt apologies” and took responsibility for her role in the tragic death. She had also undertaken various courses on medication errors.

When does the system — and its leaders — get held accountable for systemic mistakes?

Sending nurses to “various courses on medication errors” will fix what exactly?

If this is all so important (and it is), why are key processes being audited just for three months? Shouldn't that be an ongoing management process? And “audit” shouldn't mean “blame the nurses if they didn't follow protocol.” Why didn't they — or why couldn't they — follow protocols? Lack of time? Chaotic conditions?

Again, as Dr. W. Edwards Deming always said, I believe senior leaders are responsible for the system.

Dr. W. Edwards Deming – “People work in the system that management created”

As the late Paul O'Neill, former CEO of Alcoa said, leaders are responsible for everything that happens in their organization — like it or not. If you don't like it… don't take that leadership role (and that leadership paycheck).

Leadership is all about obligation and nothing about privilege. The obligation of leaders. This sounds like servant leader language, where he would say leaders are personally responsible for everything that goes on in their facility, including, most importantly, for everything gone wrong.


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Mark Graban
Mark Graban is an internationally-recognized consultant, author, and professional speaker, and podcaster with experience in healthcare, manufacturing, and startups. Mark's new book is The Mistakes That Make Us: Cultivating a Culture of Learning and Innovation. He is also the author of Measures of Success: React Less, Lead Better, Improve More, the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, and the anthology Practicing Lean. Mark is also a Senior Advisor to the technology company KaiNexus.

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