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Should disciplinary action be taken against those who make multiple or catastrophic errors?

From the April 8, 1998 issue

Non-punitive reporting systems and handling employees who make multiple or catastrophic errors are frequent topics raised by health care managers and practitioners who contact us. This subject was discussed at length recently during a conference call led by Lucian Leape, MD, of the Institute for Healthcare Improvement (IHI) and Judy Smetzer, RN of ISMP. Both are serving as faculty for an ADE prevention collaborative now underway through IHI. The need for leadership understanding and a solid commitment to a non-punitive approach to errors were stressed during the call. Employees are blamed for errors when administrative leadership is unaware of the significant influence of the system on individual performance. A non-punitive approach is not possible unless there is support from top leaders - all the way up the leadership chain - who truly understand that errors are just symptoms of a "diseased" system, and that error prevention efforts must be directed at the weaknesses in the system, not at individuals.

Several techniques were suggested for creating a non-punitive environment that supports increased error reporting. A confidential reporting system where everyone understands that errors will not be linked to performance appraisals is critical. Make it easy to report errors, reward error reporting and provide timely feedback to show what is being done to address problems. Apply a non-punitive approach to errors consistently! If even one person is disciplined for an error, mistakes will be hidden. Find alternate ways to evaluate employees, based not on errors or lack of making mistakes, but on positive measures that evaluate an employee's overall contribution to the organization.

A non-punitive environment is really tested when an organization is confronted with an employee who makes multiple errors or is involved in a catastrophic error. We often find it easier and in our nature to blame individuals and resort to familiar solutions: counseling, disciplinary action, enforcing rules or developing new rules. There is little or no remedial value in doing so and the easy way out often leads back to problems that persist or worsen. In fact, when the only action is punishing individuals for errors, this can actually be dangerous to an organization. It leads to the ever increasing need for more of the same familiar remedies, or the philosophy of "what we need here is a bigger hammer." The root causes of problems are not identified and the system is weakened even further.

Organizations face considerable pressure from the public and the legal system to discipline individuals for mistakes. Nevertheless, even with employees involved in multiple or catastrophic errors, there is little advantage to terminating them. It inadvertently sends the message that the organization has hired a defective employee and has not exercised good judgment in allowing the employee to provide care in the organization. Rather, it is more important to determine why errors are happening and take action to effectively prevent these errors or minimize their consequences. The goal of patient safety is best served with a non-punitive environment that places more value on reporting problems, so they can be remedied, than pursuing the largely unprofitable path of disciplining employees for errors.

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