The sexual abuse scandal at Penn State raised a lot of questions in the media regarding who knew what was happening and who failed to report the abuse to authorities. One cannot help but be appalled at the idea that witnesses or others who knew what was happening stood by and allowed it to continue. Their silence makes them complicit in the abuse of young victims who did not have a voice. None of us would agree that this is acceptable.
Yet, how many of us have been witness to unsafe or unethical practices in our place of employment and failed to act. Most of us have, hopefully, not been witness to something as heinous as sexual abuse of a minor. But we must ask ourselves whether we have failed to act in other ways, and perhaps put the well-being of our patients or our coworkers at risk.
In 2000, the Institute of Medicine cited that 44 000 to 98 000 people died each year from medical errors.1 Despite much dialogue, publicity, regulations, and changes in procedures, there is no reliable evidence that we have made any progress.2 And, it is also not clear that all of the procedures that have been put in place make any difference. One of the difficulties in determining the error rate is lack of good data about how often errors occur in health care agencies and what type of errors those are.2
All the regulatory agencies, government oversight, rules, and regulations cannot take the place of vigilance of those at the bedside. As nurses, we are the ones who are present with the patient 24 hours a day, 7 days a week. By nature of our work, we are in positions that can allow us to observe unsafe practices by others, uncover errors, and intervene in “near miss” events that might have resulted in an error. This includes not just errors by individuals, but system problems or practices that may harm significant numbers of patients.
One of the reasons we do not have good data about numbers of errors is that health care workers are often reluctant to report errors when they occur. This underreporting makes it difficult to determine not only the number of errors happening, but what factors contribute to those errors.
Why are nurses reluctant to report errors? We are supposed to be patient advocates. The Code of Ethics for nurses clearly states that “The nurse promotes, advocates for, and strives to protect the health, safety and rights of the patient,”3 including identifying and reporting unsafe practices. This includes going outside the system to regulatory boards if necessary. This requires health care professionals to be diligent about ensuring patient safety and acting as a patient advocate. Yet it is often difficult to get nurses to report errors or near misses.
Several recent studies examined some of the reasons for this reluctance.4–7 Loyalty to coworkers is one reason, particularly if the relationship is a close one. Nurses expressed difficulty in reporting an incident if a personal or professional relationship might be affected. Loyalty to an employer may also have some effect as well, particularly if a nurse has a strong link with self-identity and belonging to an organization. Some nurses reported that they did not report incidences if they seemed minor or if no harm came to the patient. The difficulty with this approach is that it puts individuals in a position of deciding what is minor, and fails to uncover problems that could become more serious in the future. Another common reason was that nurses felt that nothing would be done about the issue or problem.4–7 This overlooks the fact that nothing can be done about problems no one knows about. Because the person reporting the incident is not privy to all consequences or disciplinary action taken, he or she may assume nothing was done. Certainly health care agencies can work on transparency in regard to how errors are addressed, but actions regarding employees often have to be kept confidential. Perhaps the most alarming reason was that small errors that happen frequently come to be seen as normal. In this case, no one thinks of reporting them because they do not even register as errors. In some cases, it is a system design that becomes “how we do it here” and one either goes along with it or does not work there.
Nurses also weigh the consequences of reporting unsafe behavior and the likelihood of consequences and possible emotional costs.6,7 Fears of retaliation, job loss, and ostracism by others are significant in some situations. While whistle-blower protection may protect nurses from retaliation from an employer, they do not protect them from other methods of retaliation, as in the case of the Texas nurses who reported a physician to the state medical board and were then charged with misuse of official information by the district attorney.7 While one had her case dismissed and one was acquitted, the emotional and financial cost was tremendous.
Obviously if we are going to improve the safety and efficacy of the care we give, we need to be able and willing to identify errors, near misses, and problems in process without the fear of reprisal. Failing to report is to fail our duty to our patients. It also fails to highlight processes that may cause someone else to make the same mistake. We cannot go another 10 years, hoping to improve on the Institute of Medicine report. As individuals, we can encourage one another to fill out occurrence reports, even on things that seem small. We must report not only errors by others but those we make ourselves and refrain from encouraging a culture of silence among our coworkers. We cannot assume that nothing will be done. Nothing can be done if it is not reported in the first place. We must also advocate for policies and laws that protect nurses who come forward, not only from retaliation from coworkers and employers, but from criminal prosecution and civil suits as well. It is our ethical duty to be advocates for our coworkers and our patients.
1. Institute of Medicine. To Err Is Human. Building a Safer Health System. Washington, DC: National Academies Press; 2000.
3. American Nurses Association. Guide to the Code of Ethics for Nurses. Interpretation and Application. Silver Spring, MD: American Nurses Association; 2010:23. Nursesbooks.org
4. Grube GA, Piliavin JA, Turner JW. The courage of one's conviction: when to nurse practitioners report unsafe practices. Health Commun. 2010;25:155–164.
5. Jackson D, Peters K, Andrew S, et al. Understanding whistle blowing: qualitative insights from nurse whistleblowers. J Adv Nurs. 2010;66:2194–2201.
6. Peters K, Luck L, Hutchinson M, Wilkes L, Andrew S, Jackson D. The emotional sequelae of whistle blowing: findings from a qualitative study. J Clin Nurs. 2011;20:2907–2914.
7. Black LM. Tragedy into policy. A quantitative study of nurses' attitudes toward patient advocacy activities. Am J Nurs. 2011;111:26–35.