1. Copeland, Donna DNP, RN, NE-BC, CPN, CPON, AE-C


Historically, healthcare has accepted a culture of individual blame and punishment following an adverse event. Blame leads to under-reporting of errors due to the fear of reprisal. Consequently, under-reporting results in missed opportunities for nursing leaders to recognize and improve system breakdowns in mitigating recurrence. A quality improvement effort targeting staff's fear of reporting was launched to improve the culture of safety.