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If you work in a hospital or other healthcare setting, you cannot help hearing about patient safety. The public outcry created by the Institute of Medicine's (IOM) report on medical errors has forced all of us to look more closely at patient safety and how we can prevent errors from occurring.1 Regulatory agencies such as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO)2 have established guidelines meant to decrease the number of errors that happen because of failures in the healthcare system. In 2005, the Patient Safety and Quality Improvement (PSQI) Act was passed, with the goal of reducing the incidence of errors and providing a mechanism to report errors anonymously to nonprofit safety organizations.3

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Following the report by the IOM, there has been a significant focus on "systems errors." The premise is that most errors happen because of faults in the "system." This is undoubtedly true. There are numerous accounts of errors that happen because of multiple problems and multiple individuals. Wachter and Shojania, in their book Internal Bleeding, call this the "Swiss cheese" effect. Each layer of safety we set up to prevent errors has a hole or two. Not one is foolproof. When all the holes in the slices of Swiss cheese line up at the same time, the multiple safeguards that should have prevented the problem fail.4 Many of JCAHO's National Patient Safety Goals are aimed at fixing these holes in the system that lead to operative errors, adverse medication events, falls, and other mishaps.


In addition to the focus on system errors there has been an effort to encourage caregivers and institutions to report adverse events. This is vital if we are to understand how mistakes happen and how to prevent them. A nonpunitive environment is essential if errors or near-miss events are to be reported regularly. Indeed, punishing people for inadvertent errors is unlikely to prevent them from making some other type of error later.


The idea that an error is not our fault, but the fault of the whole system in which we work, is very appealing. After all, most of us do not go to work every day planning to make a mistake that could harm a patient. I would venture to guess that most of us think of ourselves as careful, prudent healthcare providers who do a good job. We are even more pleased to think that if we do make an error, and are honest in reporting it, we will not get in trouble. Certainly a nonpunitive environment encourages us to come forward when we do make mistakes. We hope others can learn from our errors or near misses.


Think back to the last time you made an error (we all have at one time or another). Were there failures in the system that led to the problem? Perhaps the wrong drug was sent from the pharmacy. Perhaps the nurse on the shift before you failed to pass on some important information. Perhaps the physician or nurse practitioner wrote the order incorrectly. Perhaps there was a lack of documentation by one or more people. All of these are problems that lead to errors, and the system is part of the problem.


It is vital that we make our healthcare systems as safe as possible and that we learn from errors that occur. Without these systematic improvements, we will make little headway in improving care. However, I would challenge you that it is not enough. We must also be willing to hold ourselves and our coworkers individually accountable. We cannot be afraid to confront individuals who make repeated medication errors, fail to follow appropriate hand-washing techniques, or do not follow safeguards that are put in place to prevent common errors. Donald Goldmann, in a recent article on hand washing, suggests that increasing personal accountability is a vital part of decreasing the spread of antibiotic-resistant organisms.6 He notes that despite multiple changes in the system aimed at making hand hygiene easier, some individuals simply fail to wash their hands on a regular basis.6 More changes in the system are unlikely to make these individuals compliant.


For a variety of reasons, it is common for healthcare providers to bypass systems that are put in place to prevent errors.4 Sometimes the safety features make our work less efficient, more difficult, or more time consuming. We have visions of running for a COR cart that is locked behind a door for which no one can find a key. We carry medications in our pocket because it saves steps or because we cannot get them from the pharmacy quickly enough at night. We fail to label medications because we are interrupted numerous times in the process. Despite numerous studies documenting the seriousness of fatigue, we come to work without adequate rest, putting ourselves and our patients in jeopardy.5 Although we could argue that these are system problems, they are also individual problems for which we must be accountable.4,6


As nurses, we are individually responsible for providing the best care possible to our patients. To do that, we have a responsibility to follow hospital policies. We have a responsibility for making sure we are double checking every medication that we give to ensure the right patient, right medication, right dose, right time, and right route. We have a responsibility to keep up on current research and to continue to educate ourselves on best practices. We have a responsibility to come to work well rested. We have a responsibility to belong to our professional associations. We have a responsibility to hold ourselves and our coworkers to the highest possible standard.


If you are reading this editorial, I believe you are already an individual who takes your profession seriously. I hope you will encourage others to do the same. To be successful in reducing errors and making our units safer, we cannot avoid personal accountability.




1. Kohn KT, Corrigan JM, Donaldson MS. To Err Is Human: Building a Safer Health Care System. San Francisco, Calif: National Academy Press; 1999. [Context Link]


2. 2007 Hospital/Critical Access Hospital National Patient Safety Goals. Available at: Accessed January 11, 2007. [Context Link]


3. The Patient Safety and Quality Improvement Act of 2005. Available at: Accessed January 11, 2007. [Context Link]


4. Wachter RM, Shojania K. Internal Bleeding: The Truth Behind America's Terrifying Epidemic of Medical Mistakes. New York, NY: Rugged Land LLC; 2004. [Context Link]


5. Dean GE, Scott LD, Rogers AE. Infants at risk: when nurse fatigue jeopardizes quality care. Adv Neonatal Care. 2006;6:120-126. [Context Link]


6. Goldmann D. System failure versus personal accountability: the case for clean hands. N Engl J Med. 2006;355(2):121-123. [Context Link]