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What does it look like?

Duthie, Elizabeth A., PhD, RN, CPPS

doi: 10.1097/01.NUMA.0000547256.76967.9e
Feature: Safety solutions: Med administration

Blame is out; accountability is in. Learn how to distinguish between the two through the application of a medication error case study.

Elizabeth A Duthie is the director of patient safety at Montefiore Health System in Bronx, N.Y.

The author has disclosed no financial relationships related to this article.



Blame is out; accountability is in. But it's easy to confuse blame with accountability. The following article describes how to distinguish between the two to avoid blame.

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The path to nowhere: When human error is the answer

Gilda was an exemplary clinical nurse. Her personnel file bulged with complimentary letters from patients and appreciative novice nurses. In her 18th year in practice, she made her first medication error. She hung penicillin for Adam Jones, a penicillin-allergic patient. Fortunately, Gilda swiftly realized the mistake. She confessed her error and apologized, but Adam's wife, Suzy, reacted in fear and anger, screaming about murder and promising to get Gilda fired. The error was labeled a near miss because it never reached the patient, but it certainly felt like the real deal to Gilda at the time.

Gilda was devastated. Speedy recognition of the error and her own intervention saved the day, but she didn't understand how it happened. The floor wasn't busy, staffing was fine, she felt rested, and there were no other emergencies. She was honest and apologized, but it didn't diminish Suzy's fatigue-driven outburst. Her screaming threat to have Gilda fired still echoed in Gilda's ears. The look of fear on Adam's face haunted her. Gilda needed this job, but maybe she should be fired. She worried that she was losing her skills, becoming a menace to her patients. She submitted the incident report, contacted the resident, requested another dose of penicillin from the pharmacy for the intended patient, and stayed an hour late to ensure that he received it. Gilda hoped her nurse manager, Caroline, would help make sense of it all.

Gilda met with Caroline the next day. Gilda accepted responsibility for the error, revealing that she had forgotten to check the patient's identification bracelet. Caroline reassured Gilda that she was a good nurse and one error didn't define who she is. She advised Gilda not to be too hard on herself. However, Caroline urged Gilda to take the incident as a warning that she always had to be vigilant when giving medications; the five rights had to be followed. Staying focused was absolutely essential for every dose of medication administered. Caroline comforted Gilda and reassured her that she wouldn't lose her job; she was still highly valued. Gilda was grateful for Caroline's support, but still felt shaken and helpless. She took her responsibilities seriously and was vigilant. She had never made a medication error before. Maybe Suzy's rant was right, and she didn't deserve to be a nurse any longer.

Gilda now felt unsure when giving medications and constantly rechecked herself. Although Caroline told her she was a good nurse, Gilda had trouble believing it. She was told that she made a human error, but it felt like she had been labeled a human error. The free fall from revered colleague to unsafe person who makes medication errors was dark and bewildering.

Caroline had been a nurse manager for 12 years. She felt sorry for Gilda, who was visibly distressed by the incident and who had always been an excellent nurse. Caroline completed the mandatory event report and assigned human error as the cause of the incident. Under the proposed solutions section, she wrote that Gilda had been counseled to follow the five rights of medication administration.

Only hours after submitting the report, Caroline received a call from the patient safety manager, Molly. She informed Caroline that event review is required whenever the resolution is to follow the five rights of medication administration. Caroline was annoyed and frustrated. Gilda had acknowledged her error. Clearly, they knew what had happened. If Gilda had simply followed the rules, the error wouldn't have occurred. Caroline explained to Molly that she had done a thorough investigation and spent considerable time consoling Gilda. She didn't want her work undermined by upsetting Gilda with an interrogation. Molly reassured Caroline that the focus was to learn from Gilda, not to interrogate her.

Caroline felt that she couldn't refuse and reluctantly agreed. After all, how would it look if she were against patient safety? But wasting everyone's time when the reason for the error was well understood was unacceptable. She held her staff to high standards. If you couldn't even tell staff members to follow something as basic as the five rights of medication administration, did any rules matter? She was asking Gilda to be responsible for her actions. She wasn't blaming her; she was expecting accountability. Apparently, that wasn't good enough. She would bring this up with Molly during the follow-up meeting after Molly discovered what Caroline already knew, which was that there was nothing else to be done because no one was hurt, no one is perfect, and mistakes happen. Caroline often thought that being a nurse manager with so much outside interference was exhausting.*

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Fulfilling the potential of a just culture: Learning from errors

Let's pause this narrative for a moment to consider a just culture. The goals of a just culture are to ensure that staff members aren't unfairly punished when an error occurs, achieve trusting relationships, and learn from events to make the organization safer.1-2 Did Caroline's handling of the event meet the expectations for a just culture? Did Caroline avoid blame and wisely apply accountability? Caroline's nurturing response supported trusting relationships and she didn't punish human error. But there was no learning because Caroline's solution was to fix the person. Despite her good intentions and compassionate response, Caroline inadvertently blamed Gilda by holding her responsible for her actions. In a just culture that values accountability, we hold people responsible for their decisions.3-4 The focus of Molly's event review was to support learning by identifying the decision that led to the unintended event.

As soon as she met Molly, Gilda described how upset she was about the event. Gilda didn't know what to do differently because she clearly knew that she should've checked the patient's identity. Could this happen again? She was feeling nervous and anxious administering medications despite her unblemished 18-year record. Molly reassured her that she was highly regarded and if this error could happen to her, it could happen to anyone. The goal was to prevent the error for all nurses administering medications. Error prevention starts with knowing why the error occurred. Forgetting to check the patient's identity was “what” happened. They needed to appreciate “why” it had happened. Understanding the full story, including the circumstances leading up to the event, was crucial.5

Gilda reported that she was on the way to room 416 to give John Smith his antibiotic when Suzy in room 412 invited her to hear good news. Gilda entered room 412 with the antibiotic in hand. Suzy was happy to report that Adam's abdominal abscess was to be treated with antibiotics and he wouldn't need surgery. In thinking back, Gilda estimated that the word antibiotic must have come up at least five times during the discussion. As she was leaving room 412, Gilda looked down, saw the drug, and thought, “Oh no, I forgot to give him his antibiotic.” She hung it not realizing she hadn't performed the identification checks. When she went to document the drug at the medication cart, she recognized that she gave the medication to the wrong patient. She immediately took the drug down before the medication had time to reach the patient's bloodstream.

James Reason, the father of human error theory, tells us that we can't change what we never intended to do.2 We can only change the decision that led to the error.3-4 Gilda didn't decide to omit checking the patient's ID bracelet. Instead, she decided to respond to Suzy's request to come into her husband's room. Once Gilda went into the room, typical cognitive errors occurred. She had a memory lapse, forgetting the medication was intended for another patient. Calling Adam by his name told her she knew the patient and fooled her brain into thinking she had performed the identification checks. The discussion about antibiotics sent a subliminal message that connected the drug in Gilda's hands to this patient. These cognitive human errors were outside of Gilda's control. The decision to enter the patient's room with a medication intended for another patient was within her control. Gilda could've easily told Suzy, “I really want to hear your news. Let me give this medication and when I return, I can give you my full attention.”

The organization had no policy about interruptions during medication administration. The medication administration policy was changed to require nurses to take medications directly to the intended patient and not to respond to avoidable interruptions. The event was also added to a list of errors supporting the need for medication barcode scanning. When the mind is engaged in several activities and distracted from the immediate task at hand, an effective attentional alert has the potential of refocusing our attention.6 The procedure at that time directed nurses to read the dual identifiers (patient name and date of birth) from the patient's identification band. Reading the bracelet is an error prone process; seeing what we expect to see, instead of what's actually present, is a common error (confirmation bias error).6

The event was referred to the nursing practice council to change the process to one that requires active patient engagement. The patient would be asked to give his or her name and date of birth while the nurse reads the same information on the medication label. Had this practice been in place, the error may have been intercepted because Adam may have inquired about the verbal check before Gilda gave the medication.

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Distinguishing blame from accountability

Blame holds individuals responsible for events outside of their control.3 Gilda's errors involved normal cognitive processes over which she didn't have control. Her failure to verify the patient's identity wasn't a decision to disregard the five rights of medication administration. Caroline's well-intentioned warning was a futile solution that created fear, leaving Gilda with no strategies to prevent the error and no understanding of how it had happened, just anxiety that it might happen again. If it did, it would surely be from a lack of vigilance, but at the time Gilda didn't realize she wasn't being vigilant. If you aren't aware you have a problem, how do you fix it?

Despite Caroline's support, Gilda carried the threat of failure in her worried heart. Gilda felt relieved after the incident review meeting. Avoiding interruptions and engaging the patient in the process felt empowering; she had tangible fixes. In the future, if Gilda intentionally responded to an avoidable interruption or purposefully disregarded active engagement before medication administration, she should be held responsible for not following patient safety practices. Gilda shared with Caroline her relief and her newfound strategies. She also inquired about how to join the practice council.

Caroline was impressed with the findings, but was troubled to think her actions constituted blame. She hadn't punished Gilda. Wasn't avoiding unfair punishment the goal of a just culture? Molly affirmed that Caroline had treated Gilda compassionately. Caroline didn't decide to blame Gilda. We can't change what we never intended to do. We can only change the decision that led up to that event. What was Caroline's decision? She decided to support Gilda and communicate high standards, which included following procedures. The problem is that Gilda never intended to break the rules. The lack of a support systems (active patient engagement, guidance about avoiding interruptions, barcode scanning of medications) ensured that Gilda fell prey to normal cognitive processes. Caroline's actions were consistent with the organizational mandate not to unfairly punish nurses when an error occurred.

The patient safety department had only been in place 10 months and the focus on learning from errors wasn't well understood. Nurse managers hadn't been educated about systems or provided with new skills for incident investigation. Molly acknowledged the lack of organizational support for Caroline and reassured her that her follow-up met the expectations for nurse managers. A function of the patient safety department was to learn from errors for future prevention. This meant that errors involving nurses were no longer the sole responsibility of the manager but instead would be shared across the departments.

Forging a collaborative relationship was an emerging process. In response to Caroline's request, Molly committed to developing classes for the nurse managers about incident investigation. Caroline gave Molly permission to share the story at the nurse manager council without mentioning her name or unit.

So, what does blame look like? In Caroline's hands, it was kind, nurturing, and well intentioned. It looked fair because no one was punished. It generated fear for Gilda, who was powerless to follow the advice. Blame disguised itself as supporting a just culture. In another hospital, a nurse was punished when the decision to omit barcode scanning of medications was interpreted as egregious rule breaking. The facts that there were no handheld scanners, the carts only fit into the room if you moved furniture and visitors, and workarounds were widespread were ignored and punishment justified as promulgating best practices. Seeking to understand or learn from errors was seen to be sending a wrong message to staff that rules aren't important.

The belief that rule breaking is always under the person's control is at odds with human error theory.2 Rule breaking viewed without context leads to organizational blindness; they see nothing they can fix. The shattered rules are evident; we desperately want to believe that if law is restored, order will follow. Blame is sneaky. It has been known to masquerade as accountability when the underlying decision is ignored. To be honest, the answer to what blame looks like eludes me. It looks different every time I see it. So, what should we do?

Concentrate on understanding why individuals thought they were doing the right thing instead of looking to prove why they went wrong.7 Listen to the stories to illuminate their decisions. Often, the involved clinicians don't understand the decision and will need guidance to understand why they did what they did. Discern the intentions from the clinician's viewpoint. What did he or she hope the decision would achieve? Spend more time on learning than on ascertaining punishment.

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Look forward, not backward

Blame is backward looking, focusing on changing the individual. We're no safer after the event than we were before. Accountability is forward looking, seeking improvement through building stronger systems.8 When we learn from small events to achieve organization-wide change, we protect patients and support staff.9 We need to build an accountable culture by seeking to understand and holding individuals responsible for their decisions.

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1. Dekker S. Just Culture: Balancing Safety and Accountability. Burlington, VT: Ashgate; 2007.
2. Reason JT. Managing the Risks of Organizational Accidents. Brookfield, VT: Ashgate; 1997.
3. Duthie EA. Accountability: challenges to getting it right. J Patient Saf. 2018;14(1):3–8.
4. Marx D. Whack A Mole: The Price We Pay for Expecting Perfection. Plano, TX: By Your Side Studios; 2009.
5. Woods DD, Dekker S, Cook R, Johannesen, Sarter N. Behind Human Error. 2nd ed. Burlington, VT: Ashgate; 2010.
6. Reason JT. Human Error. Brookfield, VT: Ashgate; 1990.
7. Dekker S. The Field Guide to Understanding Human Error. 3rd ed. Boca Raton, FL: CRC Press; 2014.
8. Sharpe VA. Behind closed doors: accountability and responsibility in patient care. J Med Philos. 2000;25(1):28–47.
9. Institute of Medicine. To Err is Human: Building a Safer Health System. Washington, DC: National Academies Press; 2000.

* The cases are composites and not from a single organization.
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