News Release

ISMP Opposes Criminal Charges for Wisconsin Nurse Involved in Medication Error

Last week, a nurse from Wisconsin was charged with “criminal neglect of a patient causing great bodily harm” in the medication error-related death of a 16-year-old woman during labor. The Institute for Safe Medication Practices (ISMP) supports the stance taken by the Wisconsin Hospital Association and Wisconsin Nurses Association that criminal prosecution of a healthcare professional for an unintentional error is inappropriate and unwarranted.

Like so many other healthcare professionals and organizations around the country, ISMP’s staff members were deeply saddened by the tragic loss of life in this case and extend their condolences to the patient’s family.  

When a fatal medication error occurs, there often is considerable pressure from the public and the legal system to blame and discipline individuals for mistakes. However, criminal prosecution sends the false message that clinical perfection is an attainable goal, and that “good” healthcare practitioners never make errors.  

Practitioners begin to fear disciplinary action if they make a mistake, and reporting of errors decreases, making it more difficult to determine root causes. The belief that a medication error could lead to felony charges, steep fines, and a jail sentence also can have a chilling effect on recruitment and retention of healthcare providers--particularly nurses, who are already in short supply.

ISMP strongly believes in adoption of a Just Culture in healthcare that fairly balances individual and health system accountability when errors happen, and does not assume that healthcare providers will perform flawlessly at all times. Just Culture promotes reporting of risk and actual errors, analysis of the system-based causes of errors, and identification of the safest behavioral choices for healthcare providers who work within the healthcare system.  

The goal of patient safety is better served by determining the system-based weaknesses that led to this error, sharing lessons learned with others, and taking action to prevent similar errors, rather than engaging in egregious criminal prosecution of a single individual.  

About ISMP: The Institute for Safe Medication Practices (ISMP) is a 501c(3) nonprofit organization that works closely with healthcare practitioners and institutions, regulatory agencies, consumers, and professional organizations to provide education about medication errors and their prevention. ISMP represents more than 30 years of experience in helping healthcare practitioners keep patients safe, and continues to lead efforts to improve the medication use process.

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