Beyond Blame: How Punishing Healthcare Workers Fails to Prevent Medication Errors


In healthcare, leaders saying “we'll hold them accountable” too often means, in reality, “we'll punish individuals for mistakes that have many systemic causes.”

To the extreme side of this spectrum, a nurse, RaDonda Vaught, was criminally prosecuted and convicted as an individual, while the organization and its leaders she worked for were not “held accountable” to a similar extent. What happened to her was unjust. 

How does naming, blaming, and shaming individual caregivers do anything to reduce the number of medication errors and the amount of harm to patients going forward?

Can anybody show me the data that proves that punishment (and the threat of it) reduces errors and harm, either locally or nationally? 

If anything, we might have data that shows a reduction in “reported events” — which is, of course, not the same as “actual events.” A culture of fear and punishment teaches people to hide mistakes (and especially near misses) when they can. Then, learning can't happen. We're doomed to more mistakes.

We need to shift away from a culture of fear and punishment to a healthcare culture that focuses on PREVENTING mistakes (systematically and not just telling people to be careful) and then LEARNING from each mistake that does happen.

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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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