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Lesson from Denver: look beyond blaming individuals for errors

From the Feb. 11, 1998 issue

The "jury is in" on the case of the nurse charged with criminally negligent homicide in an infant's death from a medication error. After about 45 minutes of deliberation, the jury not only acquitted the nurse, but the jurors also offered their support, crying and hugging the nurse after the verdict was delivered. Two other nurses indicted in this case accepted a deferred guilty plea prior to trial, in part, because they were afraid that a jury would render a single verdict for all three of them. The two nurses believed that they had a more prominent role in the medication error, and they did not want the third nurse found guilty by association when her role in the error was negligible.

Despite community pressure for individual accountability, the hospital where the error occurred provided significant support to all three nurses involved in the medication error. The nurse standing trial remained employed throughout the trial and continues to work in the newborn nursery. One of the other nurses lost her license to practice for one year, but the hospital continued to employ her as a unit secretary until she could again work as a nurse. The hospital and medical staff rallied in support of the individuals involved in the medication error, recognizing that errors belong to the system, not just individuals. In addition, the hospital provided the funds for all the nurses' defense since, typically, professional liability insurance does not cover expenses for criminal charges. With this visible show of support, the hospital has taken a giant step forward to create the environment necessary to make significant changes in medication error prevention.

Along with others who donated their time to support this case, ISMP provided a systems analysis and expert testimony at trial. We identified over 50 different failures in the system that allowed this error to occur, go undetected, and, ultimately, reach a healthy newborn child, causing his death. Had even just one of these failures not occurred, either the accident would not have happened, or the error would have been detected and corrected before reaching the infant. Since most of what people do is governed by the system, the causes of errors belong to the system and, consequently, often lie outside the control of individuals, despite their best efforts. This case provides clear evidence that medication errors are almost never caused by the failure of a single element or the fault of a single practitioner. Rather, a catastrophic event such as this is the result of the combined effects of "latent failures" in the system and "active failures" by individuals.1

Latent failures are weaknesses in the structure of an organization, such as faulty information management or ineffective personnel training, that result from both good and ill-conceived decisions made by upper management. By themselves, latent failures are often subtle and may cause no problems. Their consequences are hidden, becoming apparent only when they occur in proper sequence and combine with active failures of individuals to penetrate or bypass the system's safety nets. Many of the latent and active failures that were at the root of this medication error are identified in the accompanying article on page 2 of this issue. Providing an optimal level of medication safety requires that we recognize and correct the latent failures in the system. We must look beyond blaming individuals and focus on the multiple underlying system failures which shape individual behavior and create the conditions under which medication errors occur. And by their verdict, this is the lesson that the Denver jury wants us to learn.

1. Reason, J. The contribution of latent human failures to the breakdown of complex systems. Philosophical Transactions of the Royal Society of London B, 1990; 327, 475-484.

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