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From the May 19, 2005 issue

Despite widespread recognition that blame, shame, and punishment for mistakes are tremendously counterproductive to patient safety, responses to our February 24, 2005, survey from 1,572 licensed healthcare providers suggest that participants still fear punitive action from their licensing boards in the wake of a medication error.

General results. As expected, participants anticipated an increasing severity of punishment by the licensing boards as the patient outcome worsened. For example, 93% of respondents believed their licenses would be restricted in some fashion if involved in a fatal medication error. At least one in three respondents thought their license would be placed on probation (41%) or suspended (33%), and about one in five (19%) thought it would be revoked. If the patient was harmed but did not die, 22% believed license probation would result, 6% felt license suspension would occur, and just 1% felt that license revocation would occur. One in six (16%) also felt there would be a monetary fine included for fatal errors, and 7% thought this would also occur with an otherwise harmful event. Half of all participants believed that remedial education would be required in the wake of either a harmful or fatal medication error.

Many respondents clearly feared licensing action if an error involved a policy violation, or if three errors or more were reported to their licensing board, regardless of severity or patient outcome. For a policy violation, 39% thought it would result in a written reprimand; 40% believed remedial education would be required; and almost half felt that action would be taken against their license in the form of probation (24%), suspension (17%), or revocation (6%). Similar fears were expressed if three or more errors were reported to the board within 1 year. However, even more respondents felt that their licenses would be placed on probation (34%), suspended (24%), or revoked (14%) under this condition. Almost one in five also thought that notification to other states in which they were licensed would be required if three or more errors were reported annually.

Surprisingly, 30% of respondents felt that they would receive a verbal or written reprimand, or be required to obtain remedial education, even if the reported medication error never reached the patient! While a reprimand may not seem as punitive as license restrictions, still, these actions often become part of the professional’s licensing records, at least temporarily.

Differences between the professions. Overall, physician respondents (n=36) expected less punitive action from their licensing boards than nurses (n=1,094) and pharmacists (n=326), particularly for intercepted or minor errors. Licensed practical nurses (n=64) expected the most punitive action from their boards, regardless of the type or severity of the error. Pharmacists and physicians anticipated less remedial education than nurses for potentially harmful errors and policy violations. With the exception of remedial education, registered nurses and pharmacists expected about the same results from their licensing boards when involved in a medication error. Clinicians who were also attorneys (n=38) generally expected the licensing bodies to mete out more serious license restrictions and more remedial education.

Differences if error reported. Punitive actions were anticipated more often among the respondents (n=50) who had experienced a medication error that had been reported to their licensing body within the last 5 years. This subset of individuals reported more anticipated verbal and written reprimands in all categories except minor or intercepted errors. However, for minor and intercepted errors, there was often an increase in the anticipated remedial education.

This subset also felt there would be greater penalties against their licenses, especially for fatal errors, policy violations, and three or more errors reported per year. For a policy violation, 36% of the subset expected license probation, 24% expected license suspension, and 12% anticipated license revocation, compared to 24%, 17%, and 5% respectively from respondents who had not had an error reported to the licensing body. For three or more errors per year, 56% of the error group expected probation, 34% expected suspension, and 22% anticipated license revocation, compared to 33%, 24%, and 12% respectively. This subset of individuals also reported a greater expectation of monetary fines for all categories except intercepted errors.

Interestingly, respondents who are, or have ever been, an employee or panel member of a licensing board (n=34) consistently expected a higher degree of punitive action in the wake of a medication error. Demographic differences between individual states could not be determined due to insufficient data among all 50 US states.

Usefulness of publications. Overall, respondents were split regarding the value of newsletters published by their licensing boards; 16% found the publications very helpful to patient safety and quality; 33% found them somewhat helpful; and 52% were not sure or did not find the publications helpful at all. Overall, licensed practical nurses found the publications most helpful, and physicians found them least helpful. However, if the “not sure” responses regarding newsletter value are removed, attorneys found the publications the least helpful, even though the information contained within primarily covers illegal activities. Pharmacists found the publications to be more helpful than did registered nurses.

Respondents who had experienced a medication error that had actually been reported to their licensing board found the newsletter less valuable than the group who had never had an error reported to the board. Conversely, 82% of respondents who are, or had ever been, an employee or panel member of a licensing board found the publication useful.

Conclusion. It’s clear from our survey that many nurses, pharmacists, and physicians believe that their licensing boards might very well take serious action against them if they are involved in a medication error, be it a near miss that never reaches the patient, or a tragically fatal error with a multitude of system-based causes. In fact, respondents who have experienced an error reported to their licensing boards within the past 5 years paint an even more ominous picture, offering confirmation that healthcare providers might, indeed, have a basis for worry.

These results describe a disconnect between healthcare providers anticipated response to an error by their licensing boards and the 1999 landmark Institute of Medicine report, To Err is Human, and advice from national safety experts, which clearly refute the value of punishment for unintentional acts such as errors.

Hopefully there are impending positive changes within the healthcare professional licensing boards in the not-too-distant future–changes brought about by healthcare’s overall evolving culture of safety. ISMP will bring any new promising initiatives by licensing boards to the attention of our readers and others. To all who participated in this survey, we thank you and will use the findings to continue our efforts on a national level to influence policy, actively promote publication of error reduction strategies in licensing body publications, and support a more just culture within the various state licensing boards. View tables with full survey data.