Non-Punitive Approach To Medication Errors

Every year there are thousands of medication errors, and most are simple mistakes made by health care professionals. Typically there is not one predominant reason that errors are made and that is the reason that telling health care professionals to be more careful is not effective. If the only reason for errors was a person not paying attention, than it would be a limited occurrence. Instead there are many issues that factor into errors, such as incorrect labels, improper communication and even oversights. The error is most commonly based on a mistake and not the sole fault of the professional’s. Dispensing errors can be a result of sloppy handwriting or a confusion about two very similarly named medications. When an error is made, it may appear that the professional should have been more diligent in their care; however one must understand that the medical field typically moves very quickly and mistakes will likely be made.

While it may seem like punishment is the most effective way of controlling medication errors, it is not. Research has shown that taking a punitive approach, actually leads to more harm and detriment to patients and the organization as a whole. If health care professionals make an error, it needs to be reported. Errors that are hidden could lead to a detrimental health effect for a patient and could lead to further legal action. While reckless behavior must be addressed, medication errors that are legitimate must be considered in a different manner than those that are true mistakes. For example, a nurse that failed to give a medication for their own personal gain would warrant disciplinary action. Whereas a nurse that followed an incorrect medication label, which ended in an error, did not knowingly disregard the patients’ health or safety. Those are


two separate incidents and even though they both resulted in an error, the behavior of the nurse was very different. A non-punitive approach is preferred because health care professionals are more likely to report them, if they are not in fear of punishment. The error can then be fixed, which ultimately limits liability and improves the care given. It also allows for the professional to see if there is something that could be changed to prevent the error from occurring again. This thereby improves safety and the overall quality of care.

In my opinion, I do feel that professionals should have a high level of accountability, especially when others’ lives are at stake. It is important that they conduct their jobs as effective and safely as possible. It is however understandable that they are humans and will likely make mistakes. I do believe the non-punitive method is the best, because it allows individuals to feel more comfortable reporting their mistakes. It should not be about getting out of trouble or hiding an error, due to punishment. The biggest goal is the safety and health of the patient, not the employment status of a health care professional.

Personal accountability and a non-punitive approach can certainly be used together. Again, humans make mistakes, however if they are reckless or act out of good faith, it should be addressed. Actually it is a high level of accountability when a nurse or other professional reports their mistake to their supervisor. It shows honesty and integrity and a willingness to admit fault thereby rectifying the situation. At first, I thought that the non-punitive approach was a simple means of getting out of trouble and not having to take responsibility for an error. After reviewing





the research and learning more about the potential of harm, it occurred to me that this is most likely the best approach. It is not about a person getting into trouble, it is about protecting the life and safety of a patient, regardless of who admits fault. Personally, if I were the victim of a medication error, I would rather a professional report it, so that it could be corrected and not lead to additional harm.

Educational and professional information suggest that medication errors are based more on a breakdown in communication than personal fault. There are many ways that these errors can occur, because there are oftentimes numerous departments involved in the administration of medication. While it is important for each department to be diligent about safety, it must be understood that mistakes will be made. Every precaution should be taken, regarding any type of mistake, however when they do occur, it should be handled appropriately at every level. Research suggests that by taking a more systematic approach to medication errors that it will assist in identifying and correcting the problem. Implementing quality assurance policies and also addressing issues like staff shortages can greatly reduce the incidents of errors.

In conclusion, it appears that the most conducive manner of dealing with errors is to implement a policy and system of reporting.  Having a reporting system in place, along with addressing potential problems that are discovered by reported errors can create a higher quality of health care. Of course personal accountability must be maintained, but it can co-exist with a non-punitive system in regards to medication errors. Identifying and correcting errors and problems is the most effective manner to improve health care and patient safety.