The Culture Of Blame In The Healthcare System

By keeping the lines of communication open between leaders and staff, healthcare organizations can encourage and empower nurses to solve blame game issues without fear of punishment by management. Leaders and nurses must work as a team and are capable of providing safe and quality environment. When an error or incident happens, many leaders investigate everything and everyone except themselves. In the process of patient care, harm might occur; the culture often prefers to blow the blame game whistle instead of learning from the mistake. Nursing in fear, often refrain to openly admit mistakes and errors, which hinder the objective to ensure everyone is cared with compassion and dignity.

In healthcare systems, there is a concept of fair and just culture. That concept is important to manage the risk. In any organization, errors can happen. But, the best first tool to understand the error is to report it when it happens. Reporting error in healthcare contributes to minimize the risk of recurring.

"Johns Hopkins patient safety experts have calculated that more than 250,000 deaths per year are due to medical error…" (John Hopkins Medicine). This soaring number has caused medical errors to become the third leading cause of death in the United States. For many people, medicine seems foreign and unknown. People who have lost loved ones due to medical error desperately look for a reason, and many times that blame falls upon doctors. Media has put a negative connotation on doctors as well, causing their reputation to plummet whenever a hospital procedure turns badly. A renown surgeon and author, Atul Gawande, uses his knowledge and experience to give people a new perspective on medicine. In the article "When Doctors Make Mistakes," Gawande uses rhetorical appeals: ethos, pathos, and logos to prove the need for a change in the medical systems and procedures. He analyzes how the public looks at doctors, giving a new perspective to enlighten the reader that even the best doctors can make mistakes.

Keeping patients safe is essential in today’s health care system, but patient safety events that violate that safety are increasing each year. It was only recently, that the focus on patient safety was reinforced by a report prepared by Institute of medicine (IOM) entitled ” To err is human, building a safer health system”(Wakefield & Iliffe,2002).This report found that approx-imately 44,000 to 98,000 deaths occur each year due to medical errors and that the majority was preventable. Deaths due to medical errors exceed deaths due to many other causes such as like HIV infections, breast cancer and even traffic accidents (Wakefield & Iliffe, 2002). After this IOM reports, President Clinton established quality interagency

It is the goal of all healthcare providers and organizations to provide quality care to all patients without error. The truth is, even healthcare providers make some mistakes. The question is, when an error occurs who is to be held responsible? Is it, the nurse who administered the wrong medication, due to being overworked and lack of staff to help? Or is it the Healthcare Organization (HCO), because they should have fixed the staffing issues. There are so many factors that contribute to an error. I believe each situation should be properly investigated, before placing blame where it should or should not be placed.

Medical errors are avoidable mistakes in the health care. These errors can take place in any type of health care institution. Medical errors can happen during medical tests and diagnosis, administration of medications, during surgery, and even lab reports, such as the mixing of two patients’ blood samples. These errors are usually caused by the lack of communication between doctors, nurses and other staff. A medical error could cause a severe consequence to the patient in cases consisting of severe injuries or cause/effect any health conditions, and even death. According to recent studies medical errors are not the third leading cause of death in the United States. (Walerius. 2016)

A “just” culture is necessary in healthcare to promote an environment where mistakes are brought out in the open and analyzed for ways to prevent errors from repeating. Therefore, there is a need for a consensus across the healthcare industry. To transform healthcare from the blame culture to a “just” culture will require change that extends beyond hospitals to the industry (Ross, 2015). The change has to be unified across all aspects of healthcare.

Preventing such hospital acquired conditions can save millions of dollars for the hospitals by sidelining unnecessary expenses for the acquired conditions. Frontline nurses can handle and prevent the occurrence of never events by incorporating a culture of safety through best nursing practices. The safety culture includes the ways in which the organization handles and reacts to issues or mistakes concerned with the safety in the organization, and also the notion the members of the organization have towards the safety. A high safety culture is crucial for preventing those errors from happening. Their occurrence can be prevented by expecting the risk in advance and embracing the evidence based practice. To minimize these errors Institute of Medicine (IOM) ordered the healthcare insurers including medicare and even the private insurance companies to provide higher incentives for the hospital acquired condition irrespective of the financial barriers and considerations. In order to motivate towards better care, IOM exhorted the insurers to encourage the hospitals following evidence based prevention strategies through rewards and provide advantageous rate adjustments for hospitals which provide quality care, and also allowing the admission of high risk patients with

A medical error can be defined as a preventable and adverse effect of care and one that changes the lives of all those involved-whether it be the patient, the nurse, or the physician (Grober & Bohnen, 2015). Prior to reading The Wall of Silence by Gibson and Singh (2003), I was unaware of not only how common medical errors in healthcare are, but also how they affect people from all walks of life. Medical errors do not only occur in underserved regions with understaffed medical facilities, but they can also occur in what many consider the “best” areas with fully staffed and fully equipped hospitals and medical centers. Before reading this text, it was my belief that errors in healthcare occurred rarely and at best, effected one patient per every

I agree with you that under reporting medical errors compromise patient safety.  It is important to report mistakes not only to appropriately follow up with the affected patient but also the improve  the protocol if its needed.  I also think that fear plays a huge part on nurses not reporting errors. I think that they are afraid of the consequences or penalties for the errors. I enjoy reading your post.

The person who committed error also feel anxiety and fear about patient and their family member’s pessimistic behavior (Koohestani & Baghcheghi, 2008). Another reason for underreporting of patient safety incidents is poor knowledge about organizational incident reporting system. Whereas, some health practitioner thinks it takes extra time for recording an adverse event accurately (Journal of Psychiatric and Mental Health Nursing, 2014).

A critical lack of availability is negatively impacting healthcare, because Information Technology (IT) lack of control over cloud computing, leading to more issues involving availability, reliability, integrity and confidentiality (Kuo, 2011). Availability is a rising risk in the healthcare fields for Information Technology (IT) management using cloud computing (Kuo, 2011). Despite the hype of cloud computing advantages, research confirmed 58% of firms using the cloud have no idea if the cloud is within the U.S. and forty-two% do not know where the cloud servers are placed (Turner, 2013).

Anyone who has been involved in a medical error has firsthand knowledge of the shame and chaos that ensues in the mind of the involved healthcare provider. And while we are trained to address the first victim, the patient, and support and apply counter measures, we are not always well prepared to address the second victim, the healthcare provider. This phenomenon is known among those who study patient safety and is well documented in the literature, but it is not universally addressed across healthcare. Prior to this event, our patient safety team at my organization had recently developed a policy for healing the healer and we were able to implement the steps in this

The last aspect in increasing public awareness involves changing the mindset of the people from individual problem to systems problem. Most people believe that medical errors are the result of the failures of individual providers. The public believes that possible solutions to medical errors are to keep health professionals with bad track records from providing care and give better training to health professionals. The IOM report stated that it is a systems problem. They emphasized that most of the medical errors are systems related and not attributable to individual negligence or misconduct. The key to reducing medical errors is to focus on improving the systems of delivering care and not to blame individuals. Health care professionals are simply human and, like everyone else, they make mistakes. Research has shown that system improvements can reduce the error rates and improve the quality of health care. A 1999 study indicated that including a pharmacist on medical rounds reduced the errors related to medication ordering by

In the course of operations, all healthcare organizations experience errors occurring. Policies and procedures must be in place in order to minimize the severity of errors and the impact on patient safety. When an error occurs, there are two types of causes of the failure”