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From the February 24, 2005 issue

More than 5 years ago, the Institute of Medicine (IOM) report, To Err is Human, drew national attention to the system-based causes of error and the need for a non-punitive, just culture of safety that promotes reporting, analysis, and prevention of errors. Building on this groundbreaking work, a 2004 IOM report, Keeping Patients Safe: Transforming the Work Environment of Nurses suggests that, while some progress has been made within healthcare organizations, two significant external barriers have seriously impeded full implementation of a non-punitive, just culture of safety:

---A persistent professional culture (nursing, in this case) that fosters unrealistic expectations of clinical perfection, and

---An external legal and regulatory environment (nursing state boards, in this case) that perpetuates an ongoing punitive focus on individuals who make errors.

The 2004 IOM report notes that, even today, nurses are educated to believe that clinical perfection is an attainable goal, and that "good" nurses do not make errors. Similar beliefs abound with physicians, pharmacists, and other professional healthcare providers. The report also suggests that this fallacy is perpetuated by litigation practices and licensing boards which have unjustly disciplined healthcare professionals who were involved in an error, but found blameless by a number of independent authoritative bodies. Two of the examples cited in the 2004 IOM report were previously described in detail in this newsletter.

In our January 13, 1999, newsletter article (Massachusetts Board action will hurt patients), we reported that, 4 years after a widely publicized fatal chemotherapy overdose, one physician, three pharmacists, and 18 nurses were unjustly reprimanded by their state licensing boards, regardless of findings of no fault by the state health department, Joint Commission, and National Institutes of Health. In our February 11, 1998, newsletter article (Lessons from Denver: Look beyond blaming individuals), we reported that two nurses received reprimands and licensure suspension from the Colorado nursing board, and a third nurse stood trial, but was acquitted, for criminally negligent homicide charges in the medication error death of a newborn.

Sadly, not much has changed since then, especially with state licensing boards. Our most recent experience with one of the nursing state boards is just one of many examples in which healthcare professionals still face punitive action against their licenses for making medical errors. In this case, three nurses were disciplined for their involvement in a medication error, which was clearly caused by a manufacturer-admitted design flaw in a PCA pump, which allowed a hidden default setting to occur during pump programming (see the July 29, 2004 article, Misprogram a PCA pump? It's easy! for details about the error). Similar, albeit less frequent, examples can be found within physician and pharmacy state licensing boards.

In fact, in many states, one needs to look no further than professional state board publications for evidence of a punitive culture. For example, in Pennsylvania, the state nursing board funds what must be an enormous expense to send all licensed nurses a newsletter listing all disciplinary actions taken against nurses in the state. Sanctions due to involvement in medical errors are interspersed with reports of unethical or unlicensed activity, further increasing the shame and blame culture within these agencies and the profession. Furthermore, little or no information about improving patient safety or other dimensions of healthcare quality appear in the newsletters, which would certainly be a more effective use of this resource. (Licensing actions could be posted on a website for employers to reference.) Indeed, of the 27 pages of a recent state board of nursing newsletter, 18 pages covered disciplinary actions, 1 page covered mandatory reporting of license actions taken in other states, another page described how to report unethical or unlicensed activity of colleagues, and a few additional pages contained a chairperson's business message and a welcome to new board members.

The 2004 IOM report recommended sweeping changes within the state boards of nursing. Specifically, the committee felt the National Council of State Boards of Nursing, in consultation with patient safety experts and healthcare leaders, should design uniform processes and guidelines across states to better distinguish human errors from willful negligence and intentional misconduct. Stressing that this recommendation carried equal weight to all the others, the IOM committee underscored that defenses against human errors can be developed and put in place only if healthcare professionals are not afraid of disciplinary action when reporting those errors.

Of course, there may be nursing, pharmacy, and medical licensing state boards that are making great strides in changing the culture and reducing the typical shame and blame disciplinary model of dealing with practitioners who are involved in an error. But the journey is slow, and the time required to make substantial changes cannot be predicted. Much will depend on the commitment and effort each state licensing board is prepared to devote to effecting change.

Objective measurement and feedback is needed to manage any planned change successfully, and efforts to create a just culture of safety are no exception. To this end, one pivotal place to start is an initial baseline assessment of practitioners' experiences with and perceptions about their state licensing board. Please take a few minutes to complete our survey (found on page 4 of the PDF version of the newsletter, and here). Your feedback might be just what is needed to spur change.