"Most People Wouldn't": Reporting Medical Errors

Somebody on the r/nursing subreddit asked what the worst medication error was that people had seen or heard about. Almost six hundred replies came in. I've read the whole thing, and there are a few ideas I want to come back to. This is the first.

A word on the material before I use it. These are anonymous accounts. I can't verify any of them; some are secondhand, and none come with an investigation attached. So I'm not treating them as definitive case studies. What the thread does show, and maybe more usefully, is what nurses say to each other about reporting medical errors when no manager is in the room. That matters because a reporting system is not just a database. It is the endpoint of a social process: someone has to decide it is safe enough, and useful enough, to tell the truth.

Here's one I keep thinking about.

A nurse gave a baby potassium chloride over about fifteen minutes. It was supposed to infuse over several hours. She didn't catch it while it was running. She caught it when the pump alarmed that the medication syringe was empty.

Then she had to call the nurse practitioner on duty. And it was, as she put it, the one who normally humiliates and berates nurses.

She called him anyway.

He ran to the bedside. They watched the baby's monitor for thirty minutes to see whether an arrhythmia developed. It didn't. He told her to file a safety report. He told her she was “a good nurse” for telling him. And he said,

“Thank you for telling me. Most people wouldn't.”

Her reaction to that: it horrified her more than the idea that he would berate her.

The Reporting System Starts Before the Form

He did nearly everything the books say to do. He put the patient first. He didn't punish her. He thanked her. He encouraged her to use the reporting system.

In The Mistakes That Make Us, I wrote that it's important to thank people every time they report a mistake, no matter how small. He did that, at four in the morning, in a frightening situation involving a baby.

But none of that determined whether she would call him. That decision had already been made.

She made it while standing there, terrified, looking at an empty syringe. In that moment, she didn't know how he would respond. All she had to rely on was his history.

That's the part we often miss. The reporting system didn't begin when she opened the form. It began in the moment she had to decide whether calling him would make the situation better or worse. His response that night mattered. But the behavior that determined whether someone would pick up the phone may have happened weeks earlier, to somebody else, in front of witnesses.

You can't suddenly become safe to talk to on the day it counts. That reputation was built on all the days when you didn't know you were being tested.

She wrote that he was “actually very appreciative.” The word “actually” tells us what she expected.

“Most People Wouldn't”

That sentence can be read more than one way. Read generously, it's self-knowledge. He knows what he's like, and he knows what it costs for others to speak up.

Read another way, it's a judgment about everybody else. Most nurses hide things. She was the rare “good” one who didn't. From a Reddit comment, there's no way to tell which he meant.

I'm not sure it matters, because the assumption is the problem either way.

One nurse reported an error to him. From that, he concluded that most people wouldn't have. How does he know? Presumably because he doesn't hear about many errors. But that's the trap: he is treating missing data as character evidence. Some errors are reported. Some aren't. Some reach him. Some don't. Silence might mean there is nothing to report. It might also mean people have learned which reporting channels are unsafe.

A safety report is not just a record of an event. It is evidence that the event survived the social process required to report it.

We do the same thing with numbers. When reported events go down, leaders often celebrate. Fewer reports can mean fewer errors. Fewer reports can also mean people have learned what happens when they tell you. From the count alone, those two explanations are indistinguishable. That is not just a culture problem. It is a measurement problem.

The Silence That Confirms Itself

I try not to write posts where the answer is that a leader should have been a better person. He may well be a better person than his reputation suggests. He behaved well that night, under pressure, with an infant in front of him. Reputations lag, and sometimes they're just wrong.

So what makes this pattern likely, and what keeps it invisible?

The reporting system probably doesn't measure who gets told the truth. It captures the report that was filed, not the nurse's hesitation before filing it — and certainly not the reports that were never filed.

Nothing captures the reports that were never filed. His effect shows up as missing data: the nurse who doesn't call, the concern that doesn't get voiced, the report that never gets filed.

Meanwhile, his reputation isn't a secret. Every nurse on that unit knows it. They tell each other constantly. The question is whether the organization has any way to hear it before it shows up as silence, workarounds, or Reddit comments.

And the thing loops. He's harsh with people. People stop bringing him problems. He observes that people don't bring him problems and concludes they lack courage. The silence his behavior helped produce then seems to prove him right.

In the book, I described a fear factor and a futility factor — people stay quiet when speaking up is dangerous, and they stop speaking up when it changes nothing. This nurse cleared the fear factor that night. She was terrified and called anyway. But a safety system should not depend on extraordinary courage to produce ordinary truth.

There's one more thing about that night that nobody in the thread mentioned. She caught the error because a pump told her the syringe was empty. Nothing prevented several hours' worth of potassium from going into an infant in fifteen minutes. The pump didn't stop the error. The alarm didn't prevent the harm. It announced that the medication was gone. Detection is better than nothing. But detection is not the strongest form of mistake-proofing.

She filed the safety report. I'd like to know what it said about the pump. I'd also like to know whether it captured why calling him required courage.